Executive Summary : Antithrombotic

Therapy and Prevention of Thrombosis, 9th

ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines
Gordon H. Guyatt, Elie A. Akl, Mark Crowther, David D. Gutterman,
Holger J. Schunemann and for the American College of Chest
Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel

Chest 2012;141;7S-47S
DOI 10.1378/chest.1412S3
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2012 American College of Chest Physicians
 CHEST Supplement
ANTITHROMBOTIC THERAPY AND PREVENTION OF THROMBOSIS, 9TH ED: ACCP GUIDELINES

Executive Summary
Antithrombotic Therapy and Prevention of Thrombosis,
9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines
Gordon H. Guyatt, MD, FCCP; Elie A. Akl, MD, PhD, MPH; Mark Crowther, MD;
David D. Gutterman, MD, FCCP; Holger J. Schnemann, MD, PhD, FCCP; for the American
College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel*

CHEST 2012; 141(2)(Suppl):7S47S
Abbreviations: ACS 5 acute coronary syndrome; AF 5 atrial
fibrillation; AIS 5 arterial ischemic stroke; APLA 5 antiphospolipid
antibodies; ASA 5 acetylsalicylic acid; AT9 5 Antithrombotic
Therapy and Prevention of Thrombosis, 9th ed: American
College of Chest Physicians Evidence-Based Clinical Practice
Guidelines; BMS 5 bare-metal stent; CABG 5 coronary artery
bypass graft; CAD 5 coronary artery disease; CDT 5 catheter-
directed thrombosis; CHADS2 5 congestive heart failure, hyperten-
sion, age 75 years, diabetes mellitus, prior stroke or transient
ischemic attack; CSVT 5 cerebral sinovenous thrombosis; CTPH 5
chronic thromboembolic pulmonary hypertension; CUS 5 com-
pression ultrasound; CVAD 5 central venous access device;
DES 5 drug-eluting stent; GCS 5 graduated compression stockings;
HFS 5 hip fracture surgery; HIT 5 heparin-induced thrombocy-
topenia; HITT 5 heparin-induced thrombocytopenia complicated
by thrombosis; IA 5 intraarterial; ICH 5 intracerebral hemor-
rhage; IE 5 infective endocarditis; INR 5 international normalized
ratio; IPC 5 intermittent pneumatic compression; IPCD 5 inter-
mittent pneumatic compression device; IVC 5 inferior vena cava;
LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular-
weight heparin; LV 5 left ventricular; MBTS 5 modified Blalock-
Taussig shunt; MR 5 magnetic resonance; PAD 5 peripheral artery
disease; PCI 5 percutaneous coronary intervention; PE 5 pul-
monary embolism; PFO 5 patent foramen ovale; PMBV 5 percuta-
neous mitral balloon valvotomy; PTS 5 postthrombotic syndrome;
PVT 5 prosthetic valve thrombosis; r-tPA 5 recombinant tissue plas-
minogen activator; RVT 5 renal vein thrombosis; SC 5 subcuta-
neous; TEE 5 transesophageal echocardiography; THA 5 total
hip arthroplasty; TIA 5 transient ischemic attack; TKA 5 total knee
arthroplasty; UAC 5 umbilical arterial catheter; UEDVT 5 upper-
extremity DVT; UFH 5 unfractionated heparin; US 5 ultrasound;
UVC 5 umbilical venous catheter; VAD 5 ventricular assist device;
VKA 5 vitamin K antagonist
evidence, and some articles with quite extensive
summary tables of primary studies. In total, this
represented 600 recommendations summarized in
968 pages of text. Many readers responded that the
result was too voluminous for their liking or prac-
tical use.
Cognizant of this feedback, we worked hard to
minimize the length of the text for the ninth iteration
of the guidelines Antithrombotic Therapy and Pre-
vention of Thrombosis, 9th ed: American College of
Chest Physicians Evidence-Based Clinical Practice
Guidelines (AT9) without sacrificing key content. A
number of topic editors found our shortening edits
draconian, but we were determined to produce the
leanest product possible.
There were, however, a number of obstacles. In
what we believe is a key advance in AT9, we con-
ducted a systematic review of what is known about
patients values and preferences regarding antithrom-
botic therapy and included the results as an article
in AT9. In another forward step, we recognized the
problems with asymptomatic thrombosis as a surro-
gate outcome, and devised strategies to estimate
reductions in symptomatic DVT and pulmonary
embolism with antithrombotic prophylaxis. We felt it
important to explain this innovation to users of AT9,
and this meant another article.
We included, for the first time, an article on diag-
nosis addressing patients with symptoms and signs
suggesting DVT. We increased the range of interven-
tions we have covered, resulting in additional recom-
mendations. Finally, we produced many summary

TheChesteighth iteration of the American College of

Physicians Antithrombotic Guidelines pre-
sented, in a paper version, a narrative evidence sum-
mary and rationale for the recommendations, a small
number of evidence profiles summarizing bodies of
of findings tables, which offer extremely succinct and
informative presentations of best estimates of effect
and the confidence associated with those estimates.
If published in the same fashion as the Antithrom-
botic and Thrombolytic Therapy, 8th ed: American

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2012 American College of Chest Physicians
College of Chest Physicians Antithrombotic Guide-
lines, this would have resulted in a document
with . 850 pages of paper text, an unacceptable
length. Given this and with the advice of the journal,
we decided to adopt a highly focused print version
that includes only this executive summary and the
following articles:
An introduction describing the major innovations
in AT9
A methods article explaining how we devel-
oped the guidelines (a potential model for other
guideline groups interested in optimal rigor)
Recommendations and grading from each arti-
cle embedded in the table of contents of each
article
Those seeking the rationale for the recommenda-
tions, including the supporting evidence, should
access the online version of the guideline (http://
http://chestjournal.chestpubs.org/content/141/2_suppl)
that includes a narrative summaries and support-
ing summary of findings tables. The numbering indi-
cated beside the recommendations in this summary
is aligned with the sections and tables found in the
full articles. Those interested in a deeper under-
standing of the evidence can turn to online data
supplements for each of the articles that include rec-
ommendations. There, they will find evidence pro-
files (expanded versions of the summary of findings
Revision accepted August 31, 2011.
Affiliations: From the Department of Clinical Epidemiology
and Biostatistics (Drs Guyatt, Akl, and Schnemann) and Depart-
ment of Medicine (Drs Guyatt, Crowther, and Schnemann),
McMaster University Faculty of Health Sciences, Hamilton,
ON, Canada; Departments of Medicine and Family Medicine
(Dr Akl), State University of New York, Buffalo, NY; Cardiovascular
Research Center (Dr Gutterman), Medical College of Wisconsin,
Milwaukee, WI.
*For complete panel list, see: http://chestjournal.chestpubs.org/
content/141/2_suppl/2S
Funding/Support: The Antithrombotic Therapy and Prevention
of Thrombosis, 9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines received support from
the National Heart, Lung, and Blood Institute [R13 HL104758]
and Bayer Schering Pharma AG. Support in the form of educa-
tional grants were also provided by Bristol-Myers Squibb; Pfizer,
Inc; Canyon Pharmaceuticals; and sanofi-aventis US.
Disclaimer: American College of Chest Physician guidelines are
intended for general information only, are not medical advice,
and do not replace professional medical care and physician advice,
which always should be sought for any medical condition. The
complete disclaimer for this guideline can be accessed at http://
chestjournal.chestpubs.org/content/141/2_suppl/1S
Correspondence to: Gordon H. Guyatt, MD, FCCP, Department
of Clinical Epidemiology and Biostatistics, McMaster University,
Hamilton, ON, L8N 3Z5, Canada; e-mail: guyatt@mcmaster.ca
2012 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians (http://www.chestpubs.org/
site/misc/reprints.xhtml).
DOI: 10.1378/chest.1412S3
8S
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2012 American College of Chest Physicians
tables) and some tables summarizing the methods
and results, and the risk of bias, associated with the
individual studies that contributed to the evidence
profiles and summary of findings tables.
The world of medical information is rapidly becom-
ing a world of electronic storage and presentation
of primary studies, recommendations, and a wide
variety of other information of interest to health care
practitioners. Although our abbreviated paper copy
presentation represents a necessary response to a
challenging situation, it is also a harbinger of the
increasingly electronic world of medical information
into which future editions of guidelines are destined
to move.
Summary of Recommendations
Note on Shaded Text: Throughout this guideline,
shading is used within the summary of recommenda-
tions sections to indicate recommendations that are
newly added or have been changed since the publica-
tion of Antithrombotic and Thrombolytic Therapy:
American College of Chest Physicians Evidence-
Based Clinical Practice Guidelines (8th Edition). Rec-
ommendations that remain unchanged are not shaded.
Evidence-Based Management of
Anticoagulant Therapy
For further details, see Holbrook et al.1
2.1 Loading Dose for Initiation of Vitamin K Antagonist
(VKA) Therapy
2.1. For patients sufficiently healthy to be
treated as outpatients, we suggest initiating VKA
therapy with warfarin 10 mg daily for the first
2 days followed by dosing based on international
normalized ratio (INR) measurements rather than
starting with the estimated maintenance dose
(Grade 2C).
2.2 Initial Dose Selection and Pharmacogenetic
Testing
2.2. For patients initiating VKA therapy, we
recommend against the routine use of pharma-
cogenetic testing for guiding doses of VKA
(Grade 1B).
2.3 Initiation Overlap for Heparin and VKA
2.3. For patients with acute VTE, we suggest
that VKA therapy be started on day 1 or 2
of low-molecular-weight heparin (LMWH) or
low-dose unfractionated heparin (UFH) therapy
rather than waiting for several days to start
(Grade 2C).
Executive Summary
3.1 Monitoring Frequency for VKAs
3.1. For patients taking VKA therapy with con-
sistently stable INRs, we suggest an INR testing
frequency of up to 12 weeks rather than every
4 weeks (Grade 2B).
3.2 Management of the Single Out-of-Range INR
3.2. For patients taking VKAs with previously
stable therapeutic INRs who present with a
single out-of-range INR of  0.5 below or above
therapeutic, we suggest continuing the current
dose and testing the INR within 1 to 2 weeks
(Grade 2C).
3.3 Bridging for Low INRs
3.3. For patients with stable therapeutic INRs
presenting with a single subtherapeutic INR
value, we suggest against routinely adminis-
tering bridging with heparin (Grade 2C).
3.4 Vitamin K Supplementation
3.4. For patients taking VKAs, we suggest
against routine use of vitamin K supplementa-
tion (Grade 2C).
3.5 Anticoagulation Management Services for VKAs
3.5. (Best Practices Statement) We suggest that
health-care providers who manage oral antico-
agulation therapy should do so in a systematic
and coordinated fashion, incorporating patient
education, systematic INR testing, tracking,
follow-up, and good patient communication of
results and dosing decisions.
3.6 Patient Self-Testing and Self-Management
3.6. For patients treated with VKAs who are
motivated and can demonstrate competency
in self-management strategies, including the
self-testing equipment, we suggest patient self-
management rather than usual outpatient INR
monitoring (Grade 2B). For all other patients,
we suggest monitoring that includes the safe-
guards in our best practice statement 3.5.
3.7 Dosing Decision Support
3.7. For dosing decisions during maintenance
VKA therapy, we suggest using validated deci-
sion support tools (paper nomograms or com-
puterized dosing programs) rather than no
decision support (Grade 2C).
Remarks: Inexperienced prescribers may be more
likely to improve prescribing with use of decision sup-
port tools than experienced prescribers.
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2012 American College of Chest Physicians
3.8 VKA Drug Interactions to Avoid
3.8. For patients taking VKAs, we suggest avoid-
ing concomitant treatment with nonsteroidal
antiinflammatory drugs, including cyclooxyge-
nase-2-selective nonsteroidal antiinflammatory
drugs, and certain antibiotics (see Table 8 in main
article1) (Grade 2C).
For patients taking VKAs, we suggest avoiding
concomitant treatment with antiplatelet agents
except in situations where benefit is known or is
highly likely to be greater than harm from
bleeding, such as patients with mechanical valves,
patients with acute coronary syndrome, or patients
with recent coronary stents or bypass surgery
(Grade 2C).
4.1 Optimal Therapeutic INR Range
4.1. For patients treated with VKAs, we recom-
mend a therapeutic INR range of 2.0 to 3.0 (tar-
get INR of 2.5) rather than a lower (INR , 2) or
higher (INR 3.0-5.0) range (Grade 1B).
4.2 Therapeutic Range for High-Risk Groups
4.2. For patients with antiphospholipid syndrome
with previous arterial or venous thromboembolism,
we suggest VKA therapy titrated to a moderate-
intensity INR range (INR 2.0-3.0) rather than
higher intensity (INR 3.0-4.5) (Grade 2B).
5.0 Discontinuation of Therapy
5.0. For patients eligible to discontinue treat-
ment with VKA, we suggest abrupt discontinua-
tion rather than gradual tapering of the dose to
discontinuation (Grade 2C).
6.1 Unfractionated Heparin (UFH) Dose Adjustment
by Weight
6.1. For patients starting IV UFH, we suggest
that the initial bolus and the initial rate of the
continuous infusion be weight adjusted (bolus
80 units/kg followed by 18 units/kg per h for VTE;
bolus 70 units/kg followed by 15 units/kg per h
for cardiac or stroke patients) or use of a fixed
dose (bolus 5,000 units followed by 1,000 units/h)
rather than alternative regimens (Grade 2C).
6.2 Dose Management of Subcutaneous (SC) UFH
6.2. For outpatients with VTE treated with SC
UFH, we suggest weight-adjusted dosing (first
dose 333 units/kg, then 250 units/kg) with-
out monitoring rather than fixed or weight-
adjusted dosing with monitoring (Grade 2C).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 9S
7.1 Therapeutic Dose of LMWH in Patients With
Decreased Renal Function
7.1. For patients receiving therapeutic LMWH
who have severe renal insufficiency (calculated
creatinine clearance , 30 mL/min), we suggest
a reduction of the dose rather than using stan-
dard doses (Grade 2C).
8.1 Fondaparinux Dose Management by Weight
8.1. For patients with VTE and body weight
over 100 kg, we suggest that the treatment dose
of fondaparinux be increased from the usual
7.5 mg to 10 mg daily SC (Grade 2C).
9.1 Vitamin K for Patients Taking VKAs With High
INRs Without Bleeding
9.1.
(a) For patients taking VKAs with INRs between
4.5 and 10 and with no evidence of bleeding, we
suggest against the routine use of vitamin K
(Grade 2B).
(b) For patients taking VKAs with INRs . 10.0
and with no evidence of bleeding, we suggest
that oral vitamin K be administered (Grade 2C).
9.2 Clinical Prediction Rules for Bleeding While
Taking VKA
9.2. For patients initiating VKA therapy, we
suggest against the routine use of clinical pre-
diction rules for bleeding as the sole criterion to
withhold VKA therapy (Grade 2C).
9.3 Treatment of Anticoagulant-Related Bleeding
9.3. For patients with VKA-associated major
bleeding, we suggest rapid reversal of antico-
agulation with four-factor prothrombin complex
concentrate rather than with plasma. (Grade 2C).
We suggest the additional use of vitamin K 5 to
10 mg administered by slow IV injection rather
than reversal with coagulation factors alone
(Grade 2C).
Prevention of VTE in Nonsurgical Patients
For further details, see Kahn et al.2
2.0 Hospitalized Acutely Ill Medical Patients
2.3. For acutely ill hospitalized medical patients
at increased risk of thrombosis, we recommend
anticoagulant thromboprophylaxis with low-
molecular-weight heparin [LMWH], low-dose
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2012 American College of Chest Physicians
unfractionated heparin (LDUH) bid, LDUH
tid, or fondaparinux (Grade 1B).
Remarks: In choosing the specific anticoagulant drug
to be used for pharmacoprophylaxis, choices should
be based on patient preference, compliance, and ease
of administration (eg, daily vs bid vs tid dosing), as
well as on local factors affecting acquisition costs (eg,
prices of various pharmacologic agents in individual
hospital formularies).
2.4. For acutely ill hospitalized medical patients
at low risk of thrombosis, we recommend against
the use of pharmacologic prophylaxis or mechan-
ical prophylaxis (Grade 1B).
2.7.1. For acutely ill hospitalized medical
patients who are bleeding or at high risk for
bleeding, we recommend against anticoagulant
thromboprophylaxis (Grade 1B).
2.7.2. For acutely ill hospitalized medical patients at
increased risk of thrombosis who are bleeding or
at high risk for major bleeding, we suggest the
optimal use of mechanical thromboprophylaxis
with graduated compression stockings (GCS)
(Grade 2C) or intermittent pneumatic compres-
sion (IPC) (Grade 2C), rather than no mechan-
ical thromboprophylaxis. When bleeding risk
decreases, and if VTE risk persists, we sug-
gest that pharmacologic thromboprophylaxis
be substituted for mechanical thromboprophy-
laxis (Grade 2B).
Remarks: Patients who are particularly averse to the
potential for skin complications, cost, and need for
clinical monitoring of GCS and IPC use are likely to
decline mechanical prophylaxis.
2.8. In acutely ill hospitalized medical patients
who receive an initial course of thrombopro-
phylaxis, we suggest against extending the dura-
tion of thromboprophylaxis beyond the period
of patient immobilization or acute hospital stay
(Grade 2B).
3.0 Critically Ill Patients
3.2. In critically ill patients, we suggest against
routine ultrasound screening for DVT (Grade 2C).
3.4.3. For critically ill patients, we suggest using
LMWH or LDUH thromboprophylaxis over no
prophylaxis (Grade 2C).
3.4.4. For critically ill patients who are bleeding,
or are at high risk for major bleeding, we
suggest mechanical thromboprophylaxis with
GCS (Grade 2C) or IPC (Grade 2C) until the
Executive Summary
bleeding risk decreases, rather than no mechan-
ical thromboprophylaxis. When bleeding risk
decreases, we suggest that pharmacologic throm-
boprophylaxis be substituted for mechanical
thromboprophylaxis (Grade 2C).
4.0 Patients With Cancer in the Outpatient Setting
4.2.1. In outpatients with cancer who have no
additional risk factors for VTE, we suggest
against routine prophylaxis with LMWH or
LDUH (Grade 2B) and recommend against
the prophylactic use of VKAs (Grade 1B).
Remarks: Additional risk factors for venous throm-
bosis in cancer outpatients include previous venous
thrombosis, immobilization, hormonal therapy, angio-
genesis inhibitors, thalidomide, and lenalidomide.
4.2.2. In outpatients with solid tumors who have
additional risk factors for VTE and who are at
low risk of bleeding, we suggest prophylactic-
dose LMWH or LDUH over no prophylaxis
(Grade 2B).
Remarks: Additional risk factors for venous thrombo-
sis in cancer outpatients include previous venous
thrombosis, immobilization, hormonal therapy, angio-
genesis inhibitors, thalidomide, and lenalidomide.
4.4. In outpatients with cancer and indwelling
central venous catheters, we suggest against
routine prophylaxis with LMWH or LDUH
(Grade 2B) and suggest against the prophylactic
use of VKAs (Grade 2C).
5.0 Chronically Immobilized Patients
5.1. In chronically immobilized persons residing
at home or at a nursing home, we suggest against
the routine use of thromboprophylaxis (Grade 2C).
6.0 Persons Traveling Long-Distance
6.1.1. For long-distance travelers at increased
risk of VTE (including previous VTE, recent
surgery or trauma, active malignancy, preg-
nancy, estrogen use, advanced age, limited
mobility, severe obesity, or known thrombo-
philic disorder), we suggest frequent ambula-
tion, calf muscle exercise, or sitting in an aisle
seat if feasible (Grade 2C).
6.1.2. For long-distance travelers at increased
risk of VTE (including previous VTE, recent
surgery or trauma, active malignancy, pregnancy,
estrogen use, advanced age, limited mobility,
severe obesity, or known thrombophilic disor-
der), we suggest use of properly fitted, below-
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2012 American College of Chest Physicians
knee GCS providing 15 to 30 mm Hg of pressure
at the ankle during travel (Grade 2C). For all
other long-distance travelers, we suggest against
the use of GCS (Grade 2C).
6.1.3. For long-distance travelers, we suggest
against the use of aspirin or anticoagulants to
prevent VTE (Grade 2C).
7.0 Persons With Asymptomatic Thrombophilia
7.1. In persons with asymptomatic thrombo-
philia (ie, without a previous history of VTE),
we recommend against the long-term daily use
of mechanical or pharmacologic thrombopro-
phylaxis to prevent VTE (Grade 1C).
Prevention of VTE in Nonorthopedic
Surgical Patients
For further details, see Gould et al.3
3.6 Patients Undergoing General, GI, Urological,
Gynecologic, Bariatric, Vascular, Plastic, or Recon-
structive Surgery
3.6.1. For general and abdominal-pelvic sur-
gery patients at very low risk for VTE (, 0.5%;
Rogers score, , 7; Caprini score, 0), we recom-
mend that no specific pharmacologic (Grade 1B)
or mechanical (Grade 2C) prophylaxis be used
other than early ambulation.
3.6.2. For general and abdominal-pelvic sur-
gery patients at low risk for VTE (1.5%; Rog-
ers score, 7-10; Caprini score, 1-2), we suggest
mechanical prophylaxis, preferably with inter-
mittent pneumatic compression (IPC), over no
prophylaxis (Grade 2C).
3.6.3. For general and abdominal-pelvic sur-
gery patients at moderate risk for VTE (3.0%;
Rogers score, . 10; Caprini score, 3-4) who are
not at high risk for major bleeding complica-
tions, we suggest LMWH (Grade 2B), LDUH
(Grade 2B), or mechanical prophylaxis, prefer-
ably with IPC (Grade 2C), over no prophylaxis.
Remarks: Three of the seven authors favored a strong
(Grade 1B) recommendation in favor of LMWH or
LDUH over no prophylaxis in this group.
3.6.4. For general and abdominal-pelvic sur-
gery patients at moderate risk for VTE (3.0%;
Rogers score, . 10; Caprini score, 3-4) who are
at high risk for major bleeding complications
or those in whom the consequences of bleed-
ing are thought to be particularly severe, we
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 11S
suggest mechanical prophylaxis, preferably with
IPC, over no prophylaxis (Grade 2C).
3.6.5. For general and abdominal-pelvic sur-
gery patients at high risk for VTE (6.0%;
Caprini score,  5) who are not at high risk for
major bleeding complications, we recommend
pharmacologic prophylaxis with LMWH (Grade
1B) or LDUH (Grade 1B) over no prophylaxis.
We suggest that mechanical prophylaxis with
elastic stockings or IPC should be added to phar-
macologic prophylaxis (Grade 2C).
3.6.6. For high-VTE-risk patients undergoing
abdominal or pelvic surgery for cancer who are
not otherwise at high risk for major bleeding
complications, we recommend extended-duration
pharmacologic prophylaxis (4 weeks) with LMWH
over limited-duration prophylaxis (Grade 1B).
Remarks: Patients who place a high value on mini-
mizing out-of-pocket health-care costs might prefer
limited-duration over extended-duration prophylaxis
in settings where the cost of extended-duration pro-
phylaxis is borne by the patient.
3.6.7. For high-VTE-risk general and abdominal-
pelvic surgery patients who are at high risk for
major bleeding complications or those in whom the
consequences of bleeding are thought to be
particularly severe, we suggest use of mechan-
ical prophylaxis, preferably with IPC, over no
prophylaxis until the risk of bleeding diminishes
and pharmacologic prophylaxis may be initiated
(Grade 2C).
3.6.8. For general and abdominal-pelvic sur-
gery patients at high risk for VTE (6%; Caprini
score,  5) in whom both LMWH and unfrac-
tionated heparin are contraindicated or unavail-
able and who are not at high risk for major
bleeding complications, we suggest low-dose
aspirin (Grade 2C), fondaparinux (Grade 2C), or
mechanical prophylaxis, preferably with IPC
(Grade 2C), over no prophylaxis.
3.6.9. For general and abdominal-pelvic sur-
gery patients, we suggest that an inferior vena
cava (IVC) filter should not be used for primary
VTE prevention (Grade 2C).
3.6.10. For general and abdominal-pelvic surgery
patients, we suggest that periodic surveillance
with venous compression ultrasound should
not be performed (Grade 2C).
4.0 Patients Undergoing Cardiac Surgery
4.4.1. For cardiac surgery patients with an
uncomplicated postoperative course, we sug-
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2012 American College of Chest Physicians
gest use of mechanical prophylaxis, preferably
with optimally applied IPC, over either no pro-
phylaxis (Grade 2C) or pharmacologic prophy-
laxis (Grade 2C).
4.4.2. For cardiac surgery patients whose hos-
pital course is prolonged by one or more non-
hemorrhagic surgical complications, we suggest
adding pharmacologic prophylaxis with LDUH
or LMWH to mechanical prophylaxis (Grade 2C).
5.0 Patients Undergoing Thoracic Surgery
5.4.1. For thoracic surgery patients at mod-
erate risk for VTE who are not at high risk for
perioperative bleeding, we suggest LDUH
(Grade 2B), LMWH (Grade 2B), or mechanical
prophylaxis with optimally applied IPC (Grade 2C)
over no prophylaxis.
Remarks: Three of the seven authors favored a strong
(Grade 1B) recommendation in favor of LMWH or
LDUH over no prophylaxis in this group.
5.4.2. For thoracic surgery patients at high risk
for VTE who are not at high risk for periopera-
tive bleeding, we suggest LDUH (Grade 1B) or
LMWH (Grade 1B) over no prophylaxis. In addi-
tion, we suggest that mechanical prophylaxis
with elastic stockings or IPC should be added to
pharmacologic prophylaxis (Grade 2C).
5.4.3. For thoracic surgery patients who are at
high risk for major bleeding, we suggest use of
mechanical prophylaxis, preferably with opti-
mally applied IPC, over no prophylaxis until the
risk of bleeding diminishes and pharmacologic
prophylaxis may be initiated (Grade 2C).
6.0 Patients Undergoing Craniotomy
6.4.1. For craniotomy patients, we suggest that
mechanical prophylaxis, preferably with IPC,
be used over no prophylaxis (Grade 2C) or phar-
macologic prophylaxis (Grade 2C).
6.4.2. For craniotomy patients at very high risk
for VTE (eg, those undergoing craniotomy for
malignant disease), we suggest adding pharma-
cologic prophylaxis to mechanical prophylaxis
once adequate hemostasis is established and the
risk of bleeding decreases (Grade 2C).
7.0 Patients Undergoing Spinal Surgery
7.4.1. For patients undergoing spinal surgery,
we suggest mechanical prophylaxis, prefer-
ably with IPC, over no prophylaxis (Grade 2C),
unfractionated heparin (Grade 2C), or LMWH
(Grade 2C).
Executive Summary
7.4.2. For patients undergoing spinal surgery at
high risk for VTE (including those with malig-
nant disease or those undergoing surgery with
a combined anterior-posterior approach), we
suggest adding pharmacologic prophylaxis to
mechanical prophylaxis once adequate hemo-
stasis is established and the risk of bleeding
decreases (Grade 2C).
8.0 Patients With Major Trauma: Traumatic Brain
Injury, Acute Spinal Injury, and Traumatic Spine
Injury
8.4.1. For major trauma patients, we suggest
use of LDUH (Grade 2C), LMWH (Grade 2C), or
mechanical prophylaxis, preferably with IPC
(Grade 2C), over no prophylaxis.
8.4.2. For major trauma patients at high risk for
VTE (including those with acute spinal cord
injury, traumatic brain injury, and spinal sur-
gery for trauma), we suggest adding mechan-
ical prophylaxis to pharmacologic prophylaxis
(Grade 2C) when not contraindicated by lower-
extremity injury.
8.4.3. For major trauma patients in whom
LMWH and LDUH are contraindicated, we sug-
gest mechanical prophylaxis, preferably with
IPC, over no prophylaxis (Grade 2C) when not
contraindicated by lower-extremity injury. We
suggest adding pharmacologic prophylaxis with
either LMWH or LDUH when the risk of
bleeding diminishes or the contraindication to
heparin resolves (Grade 2C).
8.4.4. For major trauma patients, we suggest
that an IVC filter should not be used for pri-
mary VTE prevention (Grade 2C).
8.4.5. For major trauma patients, we suggest that
periodic surveillance with venous compression
ultrasound should not be performed (Grade 2C).
Prevention of VTE in Orthopedic
Surgery Patients
For further details, see Falck-Ytter et al.4
2.0 Patients Undergoing Major Orthopedic Surgery:
Total Hip Arthroplasty (THA), Total Knee Arthroplasty
(TKA), Hip Fracture Surgery (HFS)
2.1.1. In patients undergoing THA or TKA, we
recommend use of one of the following for a
minimum of 10 to 14 days rather than no anti-
thrombotic prophylaxis: low-molecular-weight
heparin (LMWH), fondaparinux, apixaban, dab-
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igatran, rivaroxaban, low-dose unfractionated
heparin (LDUH), adjusted-dose VKA, aspirin
(all Grade 1B), or an intermittent pneumatic com-
pression device (IPCD) (Grade 1C).
Remarks: We recommend the use of only portable,
battery-powered IPCDs capable of recording and
reporting proper wear time on a daily basis for inpa-
tients and outpatients. Efforts should be made to
achieve 18 h of daily compliance. One panel member
believed strongly that aspirin alone should not be
included as an option.
2.1.2. In patients undergoing HFS, we recom-
mend use of one of the following rather than no
antithrombotic prophylaxis for a minimum of
10 to 14 days: LMWH, fondaparinux, LDUH,
adjusted-dose VKA, aspirin (all Grade 1B), or an
IPCD (Grade 1C).
Remarks: We recommend the use of only portable,
battery-powered IPCDs capable of recording and
reporting proper wear time on a daily basis for inpa-
tients and outpatients. Efforts should be made to
achieve 18 h of daily compliance. One panel member
believed strongly that aspirin alone should not be
included as an option.
2.2. For patients undergoing major orthopedic
surgery (THA, TKA, HFS) and receiving LMWH
as thromboprophylaxis, we recommend starting
either 12 h or more preoperatively or 12 h or more
postoperatively rather than within 4 h or less pre-
operatively or 4 h or less postoperatively (Grade 1B).
2.3.1. In patients undergoing THA or TKA,
irrespective of the concomitant use of an IPCD
or length of treatment, we suggest the use
of LMWH in preference to the other agents
we have recommended as alternatives: fonda-
parinux, apixaban, dabigatran, rivaroxaban,
LDUH (all Grade 2B), adjusted-dose VKA, or
aspirin (all Grade 2C).
Remarks: If started preoperatively, we suggest admin-
istering LMWH  12 h before surgery. Patients
who place a high value on avoiding the inconvenience
of daily injections with LMWH and a low value on
the limitations of alternative agents are likely to
choose an alternative agent. Limitations of alter-
native agents include the possibility of increased
bleeding (which may occur with fondaparinux, rivar-
oxaban, and VKA), possible decreased efficacy (LDUH,
VKA, aspirin, and IPCD alone), and lack of long-term
safety data (apixaban, dabigatran, and rivaroxaban).
Furthermore, patients who place a high value on
avoiding bleeding complications and a low value on
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its inconvenience are likely to choose an IPCD over
the drug options.
2.3.2. In patients undergoing HFS, irrespective
of the concomitant use of an IPCD or length of
treatment, we suggest the use of LMWH in pref-
erence to the other agents we have recommended
as alternatives: fondaparinux, LDUH (Grade 2B),
adjusted-dose VKA, or aspirin (all Grade 2C).
Remarks: For patients in whom surgery is likely to
be delayed, we suggest that LMWH be initiated
during the time between hospital admission and sur-
gery but suggest administering LMWH at least 12 h
before surgery. Patients who place a high value on
avoiding the inconvenience of daily injections with
LMWH and a low value on the limitations of alterna-
tive agents are likely to choose an alternative agent.
Limitations of alternative agents include the possi-
bility of increased bleeding (which may occur with
fondaparinux) or possible decreased efficacy (LDUH,
VKA, aspirin, and IPCD alone). Furthermore, patients
who place a high value on avoiding bleeding compli-
cations and a low value on its inconvenience are likely
to choose an IPCD over the drug options.
2.4. For patients undergoing major orthopedic
surgery, we suggest extending thromboprophy-
laxis in the outpatient period for up to 35 days
from the day of surgery rather than for only 10
to 14 days (Grade 2B).
2.5. In patients undergoing major orthopedic
surgery, we suggest using dual prophylaxis with
an antithrombotic agent and an IPCD during
the hospital stay (Grade 2C).
Remarks: We recommend the use of only portable,
battery-powered IPCDs capable of recording and
reporting proper wear time on a daily basis for inpa-
tients and outpatients. Efforts should be made to
achieve 18 h of daily compliance. Patients who place
a high value on avoiding the undesirable consequences
associated with prophylaxis with both a pharmacologic
agent and an IPCD are likely to decline use of dual
prophylaxis.
2.6. In patients undergoing major orthopedic
surgery and increased risk of bleeding, we
suggest using an IPCD or no prophylaxis rather
than pharmacologic treatment (Grade 2C).
Remarks: We recommend the use of only portable,
battery-powered IPCDs capable of recording and
reporting proper wear time on a daily basis for inpa-
tients and outpatients. Efforts should be made to
achieve 18 h of daily compliance. Patients who place
a high value on avoiding the discomfort and inconve-
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2012 American College of Chest Physicians
nience of IPCD and a low value on avoiding a small
absolute increase in bleeding with pharmacologic
agents when only one bleeding risk factor is present
(in particular the continued use of antiplatelet agents)
are likely to choose pharmacologic thromboprophy-
laxis over IPCD.
2.7. In patients undergoing major orthopedic
surgery and who decline or are uncooperative
with injections or an IPCD, we recommend
using apixaban or dabigatran (alternatively
rivaroxaban or adjusted-dose VKA if apixa-
ban or dabigatran are unavailable) rather than
alternative forms of prophylaxis (all Grade 1B).
2.8. In patients undergoing major orthopedic
surgery, we suggest against using IVC filter
placement for primary prevention over no throm-
boprophylaxis in patients with an increased
bleeding risk or contraindications to both phar-
macologic and mechanical thromboprophylaxis
(Grade 2C).
2.9. For asymptomatic patients following major
orthopedic surgery, we recommend against
Doppler (or duplex) ultrasound screening before
hospital discharge (Grade 1B).
3.0 Patients With Isolated Lower-Leg Injuries Distal
to the Knee
3.0. We suggest no prophylaxis rather than
pharmacologic thromboprophylaxis in patients
with isolated lower-leg injuries requiring leg
immobilization (Grade 2C).
4.0 Patients Undergoing Knee Arthroscopy
4.0. For patients undergoing knee arthroscopy
without a history of prior VTE, we suggest no
thromboprophylaxis rather than prophylaxis
(Grade 2B).
Perioperative Management of
Antithrombotic Therapy
For further details, see Douketis et al.5
2.1 Interruption of VKAs Before Surgery
2.1. In patients who require temporary inter-
ruption of a VKA before surgery, we recom-
mend stopping VKAs approximately 5 days
before surgery instead of stopping VKAs a
shorter time before surgery (Grade 1C).
2.2 Resumption of VKAs After Surgery
2.2. In patients who require temporary interrup-
tion of a VKA before surgery, we recommend
Executive Summary
resuming VKAs approximately 12 to 24 h after
surgery (evening of or next morning) and when
there is adequate hemostasis instead of later
resumption of VKAs (Grade 2C).
2.4 Bridging Anticoagulation During Interruption of
VKA Therapy
2.4. In patients with a mechanical heart valve,
atrial fibrillation, or VTE at high risk for throm-
boembolism, we suggest bridging anticoagula-
tion instead of no bridging during interruption
of VKA therapy (Grade 2C).
Remarks: Patients who place a higher value on avoid-
ing perioperative bleeding than on avoiding peri-
operative thromboembolism are likely to decline
heparin bridging.
In patients with a mechanical heart valve, atrial
fibrillation, or VTE at low risk for thrombo-
embolism, we suggest no bridging instead of
bridging anticoagulation during interruption
of VKA therapy (Grade 2C).
In patients with a mechanical heart valve, atrial fibril-
lation, or VTE at moderate risk for thromboembo-
lism, the bridging or no-bridging approach chosen is,
as in the higher- and lower-risk patients, based on an
assessment of individual patient- and surgery-related
factors.
2.5 Perioperative Management of VKA-Treated
Patients Who Require Minor Procedures
2.5. In patients who require a minor dental pro-
cedure, we suggest continuing VKAs with coad-
ministration of an oral prohemostatic agent or
stopping VKAs 2 to 3 days before the procedure
instead of alternative strategies (Grade 2C). In
patients who require minor dermatologic pro-
cedures and are receiving VKA therapy, we sug-
gest continuing VKAs around the time of the
procedure and optimizing local hemostasis
instead of other strategies (Grade 2C). In patients
who require cataract surgery and are receiving
VKA therapy, we suggest continuing VKAs
around the time of the surgery instead of other
strategies (Grade 2C).
3.4 Patients Undergoing a Minor Dental, Dermatologic,
or Ophthalmologic Procedure
3.4. In patients who are receiving acetylsali-
cylic acid (ASA) for the secondary prevention
of cardiovascular disease and are having minor
dental or dermatologic procedures or cataract
surgery, we suggest continuing ASA around the
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time of the procedure instead of stopping ASA
7 to 10 days before the procedure (Grade 2C).
3.5. In patients at moderate to high risk for
cardiovascular events who are receiving ASA
therapy and require noncardiac surgery, we
suggest continuing ASA around the time of sur-
gery instead of stopping ASA 7 to 10 days before
surgery (Grade 2C). In patients at low risk for
cardiovascular events who are receiving ASA
therapy, we suggest stopping ASA 7 to 10 days
before surgery instead of continuation of ASA
(Grade 2C).
3.6 Patients Undergoing Coronary Artery Bypass
Graft Surgery
3.6. In patients who are receiving ASA and
require coronary artery bypass graft (CABG)
surgery, we suggest continuing ASA around the
time of surgery instead of stopping ASA 7 to
10 days before surgery (Grade 2C). In patients
who are receiving dual antiplatelet drug therapy
and require CABG surgery, we suggest con-
tinuing ASA around the time of surgery and
stopping clopidogrel/prasugrel 5 days before
surgery instead of continuing dual antiplatelet
therapy around the time of surgery (Grade 2C).
3.7 Surgical Patients With Coronary Stents
3.7. In patients with a coronary stent who are
receiving dual antiplatelet therapy and require
surgery, we recommend deferring surgery for
at least 6 weeks after placement of a bare-metal
stent and for at least 6 months after placement
of a drug-eluting stent instead of undertaking
surgery within these time periods (Grade 1C). In
patients who require surgery within 6 weeks
of placement of a bare-metal stent or within
6 months of placement of a drug-eluting stent,
we suggest continuing dual antiplatelet therapy
around the time of surgery instead of stopping
dual antiplatelet therapy 7 to 10 days before
surgery (Grade 2C).
Remarks: Patients who are more concerned about
avoiding the unknown, but potentially large increase
in bleeding risk associated with the perioperative
continuation of dual antiplatelet therapy than avoid-
ing the risk for coronary stent thrombosis are unlikely
to choose continuation of dual antiplatelet therapy.
4.2 Perioperative Use of IV UFH
4.2. In patients who are receiving bridging anti-
coagulation with therapeutic-dose IV UFH, we
suggest stopping UFH 4 to 6 h before surgery
instead of closer to surgery (Grade 2C).
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4.3 Preoperative Interruption of Therapeutic-Dose
Bridging LMWH
4.3. In patients who are receiving bridging anti-
coagulation with therapeutic-dose SC LMWH,
we suggest administering the last preoperative
dose of LMWH approximately 24 h before sur-
gery instead of 12 h before surgery (Grade 2C).
4.4 Postoperative Resumption of Therapeutic-Dose
Bridging LMWH
4.4. In patients who are receiving bridging anti-
coagulation with therapeutic-dose SC LMWH
and are undergoing high-bleeding-risk surgery,
we suggest resuming therapeutic-dose LMWH
48 to 72 h after surgery instead of resuming
LMWH within 24 h after surgery (Grade 2C).
Diagnosis of DVT
For further details, see Bates et al.6
3.0 Diagnosis of Suspected First Lower Extremity
DVT
3.1. In patients with a suspected first lower
extremity DVT, we suggest that the choice of
diagnostic tests process should be guided by the
clinical assessment of pretest probability rather
than by performing the same diagnostic tests in
all patients (Grade 2B).
Remarks: In considering this recommendation, five
panelists voted for a strong recommendation and four
voted for a weak recommendation (one declined
to vote and two did not participate). According
to predetermined criteria, this resulted in weak
recommendation.
3.2. In patients with a low pretest probability
of first lower extremity DVT, we recommend
one of the following initial tests: (i) a moder-
ately sensitive D-dimer, (ii) a highly sensitive
D-dimer, or (iii) compression ultrasound (CUS)
of the proximal veins rather than (i) no diagnos-
tic testing (Grade 1B for all comparisons), (ii) venog-
raphy (Grade 1B for all comparisons), or (iii)
whole-leg ultrasound (US) (Grade 2B for all com-
parisons). We suggest initial use of a moderately
sensitive (Grade 2C) or highly sensitive (Grade
2B) D-dimer rather than proximal CUS.
Remarks: The choice between a moderately sensitive
D-dimer test, a highly sensitive D-dimer test, or prox-
imal CUS as the initial test will depend on local avail-
ability, access to testing, costs of testing, and the
probability of obtaining a negative D-dimer result if
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DVT is not present. Initial testing with US would be
preferred if the patient has a comorbid condition associ-
ated with elevated D-dimer levels and is likely to have
a positive D-dimer result, even if DVT is absent. In
patients with suspected first lower extremity DVT in
whom US is impractical (eg, when leg casting or
excessive SC tissue or fluid prevent adequate assess-
ment of compressibility) or nondiagnostic, we sug-
gest CT scan venography or magnetic resonance
(MR) venography, or MR direct thrombus imaging
could be used as an alternative to venography.
If the D-dimer is negative, we recommend no
further testing over further investigation with
(i) proximal CUS, (ii) whole-leg US, or (iii) venog-
raphy (Grade 1B for all comparisons). If the prox-
imal CUS is negative, we recommend no further
testing compared with (i) repeat proximal CUS
after 1 week, (ii) whole-leg US, or (iii) venog-
raphy (Grade 1B for all comparisons).
If the D-dimer is positive, we suggest further
testing with CUS of the proximal veins rather
than (i) whole-leg US (Grade 2C) or (ii) venog-
raphy (Grade 1B). If CUS of the proximal veins is
positive, we suggest treating for DVT and per-
forming no further testing over performing
confirmatory venography (Grade 2C).
Remarks: In circumstances when high-quality venog-
raphy is available, patients who are not averse to the
discomfort of venography, are less concerned about
the complications of venography, and place a high
value on avoiding treatment of false-positive results
are likely to choose confirmatory venography if find-
ings for DVT are less certain (eg, a short segment of
venous noncompressibility).
3.3. In patients with a moderate pretest proba-
bility of first lower extremity DVT, we recom-
mend one of the following initial tests: (i) a highly
sensitive D-dimer or (ii) proximal CUS, or (iii)
whole-leg US rather than (i) no testing (Grade 1B
for all comparisons) or (ii) venography (Grade 1B for
all comparisons). We suggest initial use of a highly
sensitive D-dimer rather than US (Grade 2C).
Remarks: The choice between a highly sensitive
D-dimer test or US as the initial test will depend on
local availability, access to testing, costs of testing,
and the probability of obtaining a negative D-dimer
result if DVT is not present. Initial testing with US
may be preferred if the patient has a comorbid condi-
tion associated with elevated D-dimer levels and is
likely to have a positive D-dimer result even if DVT
is absent. Whole-leg US may be preferred in patients
unable to return for serial testing and those with
Executive Summary
severe symptoms consistent with calf DVT. In patients
with suspected first lower extremity DVT in whom
US is impractical (eg, when leg casting or excessive
SC tissue or fluid prevent adequate assessment of
compressibility) or nondiagnostic, we suggest CT scan
venography, MR venography, or MR direct thrombus
imaging could be used as an alternative to venography.
If the highly sensitive D-dimer is negative, we
recommend no further testing over further
investigation with (i) proximal CUS, (ii) whole-
leg US, or (iii) venography (Grade 1B for all
comparisons). If the highly sensitive D-dimer
is positive, we recommend proximal CUS or
whole-leg US rather than no testing (Grade 1B
for all comparisons) or venography (Grade 1B for
all comparisons).
If proximal CUS is chosen as the initial test and
is negative, we recommend (i) repeat proximal
CUS in 1 week or (ii) testing with a moderate or
highly sensitive D-dimer assay over no further
testing (Grade 1C) or venography (Grade 2B). In
patients with a negative proximal CUS but a
positive D-dimer, we recommend repeat prox-
imal CUS in 1 week over no further testing
(Grade 1B) or venography (Grade 2B).
In patients with (i) negative serial proximal CUS
or (ii) a negative single proximal CUS and nega-
tive moderate or highly sensitive D-dimer, we
recommend no further testing rather than fur-
ther testing with (i) whole-leg US or (ii) venog-
raphy (Grade 1B for all comparisons).
If whole-leg US is negative, we recommend
no further testing over (i) repeat US in one
week, (ii) D-dimer testing, or (iii) venography
(Grade 1B for all comparisons). If proximal CUS
is positive, we recommend treating for DVT
rather than confirmatory venography (Grade 1B).
If isolated distal DVT is detected on whole-
leg US, we suggest serial testing to rule out
proximal extension over treatment (Grade 2C).
Remarks: Patients with abnormal isolated distal US
findings on whole-leg US who place a high value on
avoiding the inconvenience of repeat testing and a
low value on avoiding treatment of false-positive
results are likely to choose treatment over repeat US.
Patients with severe symptoms and risk factors for
extension as outlined in Perioperative Management
of Antithrombotic Therapy. Antithrombotic Therapy
and Prevention of Thrombosis, 9th ed: American
College of Chest Physicians Evidence-Based Clinical
Practice Guidelines are more likely to benefit from
treatment over repeat US.
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3.4. In patients with a high pretest probability
of first lower extremity DVT, we recommend
either (i) proximal CUS or (ii) whole-leg US over
no testing (Grade 1B for all comparisons) or venog-
raphy (Grade 1B for all comparisons).
Remarks: Whole-leg US may be preferred to prox-
imal CUS in patients unable to return for serial test-
ing and those with severe symptoms consistent with
calf DVT. In patients with extensive unexplained
leg swelling, if there is no DVT on proximal CUS or
whole-leg US and d-dimer testing has not been
performed or is positive, the iliac veins should be
imaged to exclude isolated iliac DVT. In patients with
suspected first lower extremity DVT in whom US is
impractical (eg, when leg casting or excessive SC
tissue or fluid prevent adequate assessment of com-
pressibility) or nondiagnostic, we suggest CT scan
venography, MR venography, or MR direct thrombus
imaging could be used as an alternative to venography.
If proximal CUS or whole-leg US is positive for
DVT, we recommend treatment rather than
confirmatory venography (Grade 1B).
In patients with a negative proximal CUS, we
recommend additional testing with a highly
sensitive D-dimer or whole-leg US or repeat
proximal CUS in 1 week over no further
testing (Grade 1B for all comparisons) or venog-
raphy (Grade 2B for all comparisons). We rec-
ommend that patients with a single negative
proximal CUS and positive D-dimer undergo
whole-leg US or repeat proximal CUS in 1 week
over no further testing (Grade 1B) or venography
(Grade 2B). In patients with negative serial prox-
imal CUS, a negative single proximal CUS and
negative highly sensitive D-dimer, or a negative
whole-leg US, we recommend no further testing
over venography or additional US (Grade 1B for
negative serial proximal CUS and for negative single
proximal CUS and highly sensitive D-dimer; Grade
2B for negative whole-leg US).
We recommend that in patients with high pre-
test probability, moderately or highly sensitive
D-dimer assays should not be used as stand-
alone tests to rule out DVT (Grade 1B).
3.5. If risk stratification is not performed in
patients with suspected first lower extremity
DVT, we recommend one of the following
initial tests: (i) proximal CUS or (ii) whole-
leg US rather than (i) no testing (Grade 1B),
(ii) venography (Grade 1B), or D-dimer testing
(Grade 2B).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 17S
Remarks: Whole-leg US may be preferred to prox-
imal CUS in patients unable to return for serial
testing and those with severe symptoms consistent
with calf DVT or risk factors for extension of distal
DVT. In patients with suspected first lower extremity
DVT in whom US is impractical (eg, when leg cast-
ing or excessive SC tissue or fluid prevent adequate
assessment of compressibility) or nondiagnostic, we
suggest that CT scan venography, MR venography,
or MR direct thrombus imaging could be used as an
alternative to venography.
We recommend that patients with a negative
proximal CUS undergo testing with a mod-
erate- or high-sensitivity D-dimer, whole-leg
US, or repeat proximal CUS in 1 week over
no further testing (Grade 1B) or venography
(Grade 2B). In patients with a negative prox-
imal CUS, we suggest D-dimer rather than
routine serial CUS (Grade 2B) or whole-leg US
(Grade 2C). We recommend that patients with
a single negative proximal CUS and positive
D-dimer undergo further testing with repeat
proximal CUS in 1 week or whole-leg US
rather than no further testing (Grade 1B for
both comparisons).
We recommend that in patients with (i) nega-
tive serial proximal CUS, (ii) a negative D-dimer
following a negative initial proximal CUS, or (iii)
negative whole-leg US, no further testing be
performed rather than venography (Grade 1B).
If proximal US is positive for DVT, we recom-
mend treatment rather than confirmatory venog-
raphy (Grade 1B). If isolated distal DVT is
detected on whole-leg US, we suggest serial
testing to rule out proximal extension over treat-
ment (Grade 2C).
Remarks: Patients with abnormal isolated distal US
findings on whole-leg US who place a high value on
avoiding the inconvenience of repeat testing and
a low value on avoiding treatment of false-positive
results are likely to choose treatment over repeat US.
Patients with severe symptoms and risk factors for
extension as outlined in Perioperative Management
of Antithrombotic Therapy. Antithrombotic Therapy
and Prevention of Thrombosis, 9th ed: American
College of Chest Physicians Evidence-Based Clinical
Practice Guidelines are more likely to benefit from
treatment over repeat US.
3.6. In patients with suspected first lower
extremity DVT, we recommend against the rou-
tine use of CT venography or MRI (Grade 1C).
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4.1 Venography in Patients With Suspected Recur-
rent DVT
4.1. In patients suspected of having recurrent
lower extremity DVT, we recommend initial
evaluation with proximal CUS or a highly sensi-
tive D-dimer over venography, CT venography,
or MRI (all Grade 1B).
Remarks: Initial D-dimer testing with a high-sensitivity
assay is preferable if prior US is not available for
comparison.
If the highly sensitive D-dimer is positive, we
recommend proximal CUS over venography, CT
venography, or MRI (Grade 1B for all comparisons).
In patients with suspected recurrent lower
extremity DVT in whom initial proximal CUS is
negative (normal or residual diameter increase
of , 2 mm), we suggest at least one further
proximal CUS (day 7  1) or testing with a mod-
erately or highly sensitive D-dimer (followed by
repeat CUS [day 7  1] if positive) rather than
no further testing or venography (Grade 2B).
Remarks: In patients with an abnormal proximal CUS
at presentation that does not meet the criteria for the
diagnosis of recurrence, an additional proximal CUS
on day 2  1 in addition to that on (day 7  1) may be
preferred. Patients who place a high value on an
accurate diagnosis and a low value on avoiding the
inconvenience and potential side effects of a venog-
raphy are likely to choose venography over missed
diagnosis (in the case of residual diameter increase
of , 2 mm).
We recommend that patients with suspected
recurrent lower extremity DVT and a negative
highly sensitive D-dimer or negative proximal
CUS and negative moderately or highly sensi-
tive D-dimer or negative serial proximal CUS
undergo no further testing for suspected recur-
rent DVT rather than venography (Grade 1B).
If CUS of the proximal veins is positive, we rec-
ommend treating for DVT and performing no
further testing over performing confirmatory
venography (Grade 1B for the finding of a new non-
compressible segment in the common femoral or
popliteal vein, Grade 2B for a  4-mm increase in
venous diameter during compression compared with
that in the same venous segment on a previous result).
Remarks: Patients with US abnormalities at pre-
sentation that do not include a new noncompressible
segment who place a high value on an accurate diag-
nosis and a low value on avoiding the inconvenience
Executive Summary
and potential side effects of a venography are likely
to choose venography over treatment (in the case
of  4-mm increase in venous diameter).
4.2 Compression Ultrasonography in Patients With
Suspected Recurrent DVT
4.2. In patients with suspected recurrent lower
extremity DVT and abnormal but nondiagnostic
US results (eg, an increase in residual venous
diameter of , 4 but  2 mm), we recommend
further testing with venography, if available
(Grade 1B); serial proximal CUS (Grade 2B) or
testing with a moderately or highly sensitive
D-dimer with serial proximal CUS as above if
the test is positive (Grade 2B), as opposed to
other testing strategies or treatment.
4.3 Pretest Probability Assessment in Patients With
Suspected Recurrent DVT
4.3. In patients with suspected recurrent ipsilat-
eral DVT and an abnormal US without a prior
result for comparison, we recommend further
testing with venography, if available (Grade 1B)
or a highly sensitive D-dimer (Grade 2B) over
serial proximal CUS. In patients with suspected
recurrent ipsilateral DVT and an abnormal US
without prior result for comparison and a nega-
tive highly sensitive D-dimer, we suggest no
further testing over venography (Grade 2C). In
patients with suspected recurrent ipsilateral
DVT and an abnormal US without prior result
for comparison and a positive highly sensitive
D-dimer, we suggest venography if available over
empirical treatment of recurrence (Grade 2C).
Remarks: Patients who place a high value on avoid-
ing the inconvenience and potential side effects of
a venography are likely to choose treatment over
venography.
5.1 Venography in Pregnancy-Related DVT
5.1. In pregnant patients suspected of having
lower extremity DVT, we recommend initial
evaluation with proximal CUS over other initial
tests, including a whole-leg US (Grade 2C), mod-
erately sensitive D-dimer (Grade 2C), highly
sensitive D-dimer (Grade 1B), or venography
(Grade 1B).
5.2 Compression Ultrasonography in Pregnancy-
Related DVT
5.2. In pregnant patients with suspected DVT in
whom initial proximal CUS is negative, we sug-
gest further testing with either serial proximal
CUS (day 3 and day 7) (Grade 1B) or a sensitive
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D-dimer done at the time of presentation (Grade
2B) over no further testing for DVT. We recom-
mend that patients with an initial negative
proximal CUS and a subsequent negative sensi-
tive D-dimer or negative serial proximal CUS
undergo no further testing for DVT (Grade 1B)
and that patients with positive D-dimer have an
additional follow-up proximal CUS (day 3 and
day 7) rather than venography (Grade 1B) or
whole-leg US (Grade 2C).
5.3 Pretest Probability in Pregnancy-Related DVT
5.3. In pregnant patients with symptoms sug-
gestive of isolated iliac vein thrombosis (swelling
of the entire leg, with or without flank, buttock,
or back pain) and no evidence of DVT on stan-
dard proximal CUS, we suggest further testing
with either Doppler US of the iliac vein (Grade
2C), venography (Grade 2C), or direct MRI
(Grade 2C), rather than standard serial CUS of
the proximal deep veins.
6.1 Ultrasonography in Patients With Upper-
Extremity DVT (UEDVT)
6.1. In patients suspected of having UEDVT, we
suggest initial evaluation with combined modality
US (compression with either Doppler or color
Doppler) over other initial tests, including highly
sensitive D-dimer or venography (Grade 2C).
6.2 Clinical Pretest Probability Assessment in Patients
With UEDVT
6.2. In patients with suspected UEDVT in whom
initial US is negative for thrombosis despite a
high clinical suspicion of DVT, we suggest fur-
ther testing with a moderate or highly sensitive
D-dimer, serial US, or venographic-based imaging
(traditional, CT scan, or MRI), rather than no
further testing (Grade 2C).
In patients with suspected UEDVT and an ini-
tial negative combined-modality US and sub-
sequent negative moderate or highly sensitive
D-dimer or CT or MRI, we recommend no fur-
ther testing, rather than confirmatory venog-
raphy (Grade 1C). We suggest that patients with
an initial combined negative modality US and
positive D-dimer or those with less than com-
plete evaluation by US undergo venography
rather than no further testing, unless there is
an alternative explanation for their symptoms
(Grade 2B), in which case testing to evaluate for
the presence an alternative diagnosis should be
performed. We suggest that patients with a pos-
itive D-dimer or those with less than complete
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 19S
evaluation by US but an alternative explana-
tion for their symptoms undergo confirmatory
testing and treatment of this alternative expla-
nation rather than venography (Grade 2C).
Remarks: Further radiologic testing (serial US or
venographic-based imaging or CT/MR to seek an
alternative diagnosis) rather than d-dimer testing is
preferable in patients with comorbid conditions typi-
cally associated with elevated D-dimer levels.
Antithrombotic Therapy for VTE Disease
For further details, see Kearon et al.7
2.1 Initial Anticoagulation for Patients With Acute DVT
of the Leg
2.1. In patients with acute DVT of the leg treated
with VKA therapy, we recommend initial treat-
ment with parenteral anticoagulation (LMWH,
fondaparinux, IV UFH, or SC UFH) over no
such initial treatment (Grade 1B).
2.2 Parenteral Anticoagulation Prior to Receipt of the
Results of Diagnostic Work-up for VTE
2.2.1. In patients with a high clinical suspicion of
acute VTE, we suggest treatment with parenteral
anticoagulants compared with no treatment while
awaiting the results of diagnostic tests (Grade 2C).
2.2.2. In patients with an intermediate clinical
suspicion of acute VTE, we suggest treatment
with parenteral anticoagulants compared with
no treatment if the results of diagnostic tests
are expected to be delayed for more than 4 h
(Grade 2C).
2.2.3. In patients with a low clinical suspicion of
acute VTE, we suggest not treating with paren-
teral anticoagulants while awaiting the results
of diagnostic tests, provided test results are
expected within 24 h (Grade 2C).
2.3 Anticoagulation in Patients With Isolated Distal
DVT
2.3.1. In patients with acute isolated distal DVT
of the leg and without severe symptoms or risk
factors for extension, we suggest serial imaging
of the deep veins for 2 weeks over initial antico-
agulation (Grade 2C).
2.3.2. In patients with acute isolated distal DVT
of the leg and severe symptoms or risk factors
for extension (see text), we suggest initial antico-
agulation over serial imaging of the deep veins
(Grade 2C).
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Remarks: Patients at high risk for bleeding are more
likely to benefit from serial imaging. Patients who
place a high value on avoiding the inconvenience of
repeat imaging and a low value on the inconvenience
of treatment and on the potential for bleeding are
likely to choose initial anticoagulation over serial
imaging.
2.3.3. In patients with acute isolated distal DVT
of the leg who are managed with initial anti-
coagulation, we recommend using the same
approach as for patients with acute proximal
DVT (Grade 1B).
2.3.4. In patients with acute isolated distal DVT
of the leg who are managed with serial imaging,
we recommend no anticoagulation if the throm-
bus does not extend (Grade 1B); we suggest anti-
coagulation if the thrombus extends but remains
confined to the distal veins (Grade 2C); we rec-
ommend anticoagulation if the thrombus
extends into the proximal veins (Grade 1B).
2.4 Timing of Initiation of VKA and Associated
Duration of Parenteral Anticoagulant Therapy
2.4. In patients with acute DVT of the leg, we
recommend early initiation of VKA (eg, same
day as parenteral therapy is started) over
delayed initiation, and continuation of paren-
teral anticoagulation for a minimum of 5 days
and until the international normalized ratio
(INR) is 2.0 or above for at least 24 h (Grade 1B).
2.5 Choice of Initial Anticoagulant Regimen in
Patients With Proximal DVT
2.5.1. In patients with acute DVT of the leg, we
suggest LMWH or fondaparinux over IV UFH
(Grade 2C) and over SC UFH (Grade 2B for
LMWH; Grade 2C for fondaparinux).
Remarks: Local considerations such as cost, avail-
ability, and familiarity of use dictate the choice
between fondaparinux and LMWH. LMWH and
fondaparinux are retained in patients with renal
impairment, whereas this is not a concern with UFH.
2.5.2. In patients with acute DVT of the leg
treated with LMWH, we suggest once- over
twice-daily administration (Grade 2C).
Remarks: This recommendation only applies when
the approved once-daily regimen uses the same
daily dose as the twice-daily regimen (ie, the once-
daily injection contains double the dose of each
twice-daily injection). It also places value on avoiding
an extra injection per day.
Executive Summary
2.7 At-Home vs In-Hospital Initial Treatment of Patients
With DVT
2.7. In patients with acute DVT of the leg and
whose home circumstances are adequate, we
recommend initial treatment at home over
treatment in hospital (Grade 1B).
Remarks: The recommendation is conditional on the
adequacy of home circumstances: well-maintained
living conditions, strong support from family or friends,
phone access, and ability to quickly return to the hos-
pital if there is deterioration. It is also conditional on
the patient feeling well enough to be treated at home
(eg, does not have severe leg symptoms or comorbidity).
2.9 Catheter-Directed Thrombolysis for Patients With
Acute DVT
2.9. In patients with acute proximal DVT of the
leg, we suggest anticoagulant therapy alone over
catheter-directed thrombolysis (CDT) (Grade 2C).
Remarks: Patients who are most likely to benefit from
CDT (see text), who attach a high value to preven-
tion of postthrombotic syndrome (PTS), and a lower
value to the initial complexity, cost, and risk of
bleeding with CDT, are likely to choose CDT over
anticoagulation alone.
2.10 Systemic Thrombolytic Therapy for Patients With
Acute DVT
2.10. In patients with acute proximal DVT of
the leg, we suggest anticoagulant therapy alone
over systemic thrombolysis (Grade 2C).
Remarks: Patients who are most likely to benefit from
systemic thrombolytic therapy (see text), who do
not have access to CDT, and who attach a high value
to prevention of PTS, and a lower value to the initial
complexity, cost, and risk of bleeding with systemic
thrombolytic therapy, are likely to choose systemic
thrombolytic therapy over anticoagulation alone.
2.11 Operative Venous Thrombectomy for Acute DVT
2.11. In patients with acute proximal DVT of the
leg, we suggest anticoagulant therapy alone over
operative venous thrombectomy (Grade 2C).
2.12 Anticoagulation in Patients Who Have Had Any
Method of Thrombus Removal Performed
2.12. In patients with acute DVT of the leg who
undergo thrombosis removal, we recommend
the same intensity and duration of anticoagu-
lant therapy as in comparable patients who do
not undergo thrombosis removal (Grade 1B).
2.13 Vena Cava Filters for the Initial Treatment of
Patients With DVT
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2.13.1. In patients with acute DVT of the leg, we
recommend against the use of an IVC filter in
addition to anticoagulants (Grade 1B).
2.13.2. In patients with acute proximal DVT of the
leg and contraindication to anticoagulation, we
recommend the use of an IVC filter (Grade 1B).
2.13.3. In patients with acute proximal DVT of
the leg and an IVC filter inserted as an alterna-
tive to anticoagulation, we suggest a conven-
tional course of anticoagulant therapy if their
risk of bleeding resolves (Grade 2B).
Remarks: We do not consider that a permanent
IVC filter, of itself, is an indication for extended
anticoagulation.
2.14 Early Ambulation of Patients With Acute DVT
2.14. In patients with acute DVT of the leg, we
suggest early ambulation over initial bed rest
(Grade 2C).
Remarks: If edema and pain are severe, ambulation
may need to be deferred. As per section 4.1, we suggest
the use of compression therapy in these patients.
3.0 Long-term Anticoagulation in Patients With Acute
DVT of the Leg
3.0. In patients with acute VTE who are treated
with anticoagulant therapy, we recommend long-
term therapy (see section 3.1 for recommended
duration of therapy) over stopping anticoagu-
lant therapy after about 1 week of initial therapy
(Grade 1B).
3.1 Duration of Long-term Anticoagulant Therapy
3.1.1. In patients with a proximal DVT of the leg
provoked by surgery, we recommend treatment
with anticoagulation for 3 months over (i) treat-
ment of a shorter period (Grade 1B), (ii) treat-
ment of a longer time-limited period (eg, 6 or
12 months) (Grade 1B), or (iii) extended therapy
(Grade 1B regardless of bleeding risk).
3.1.2. In patients with a proximal DVT of the leg
provoked by a nonsurgical transient risk factor,
we recommend treatment with anticoagulation
for 3 months over (i) treatment of a shorter
period (Grade 1B), (ii) treatment of a longer time-
limited period (eg, 6 or 12 months) (Grade 1B),
and (iii) extended therapy if there is a high
bleeding risk (Grade 1B). We suggest treatment
with anticoagulation for 3 months over extended
therapy if there is a low or moderate bleeding
risk (Grade 2B).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 21S
3.1.3. In patients with an isolated distal DVT
of the leg provoked by surgery or by a nonsur-
gical transient risk factor (see remark), we sug-
gest treatment with anticoagulation for 3 months
over treatment of a shorter period (Grade 2C)
and recommend treatment with anticoagula-
tion for 3 months over treatment of a longer time-
limited period (eg, 6 or 12 months) (Grade 1B)
or extended therapy (Grade 1B regardless of
bleeding risk).
3.1.4. In patients with an unprovoked DVT of
the leg (isolated distal [see remark] or proximal),
we recommend treatment with anticoagulation
for at least 3 months over treatment of a shorter
duration (Grade 1B). After 3 months of treatment,
patients with unprovoked DVT of the leg should
be evaluated for the risk-benefit ratio of extended
therapy.
3.1.4.1. In patients with a first VTE that is an
unprovoked proximal DVT of the leg and who
have a low or moderate bleeding risk, we suggest
extended anticoagulant therapy over 3 months
of therapy (Grade 2B).
3.1.4.2. In patients with a first VTE that is an
unprovoked proximal DVT of the leg and who
have a high bleeding risk, we recommend
3 months of anticoagulant therapy over extended
therapy (Grade 1B).
3.1.4.3. In patients with a first VTE that is an
unprovoked isolated distal DVT of the leg (see
remark), we suggest 3 months of anticoagulant
therapy over extended therapy in those with a low
or moderate bleeding risk (Grade 2B) and rec-
ommend 3 months of anticoagulant treatment
in those with a high bleeding risk (Grade 1B).
3.1.4.4. In patients with a second unprovoked
VTE, we recommend extended anticoagulant
therapy over 3 months of therapy in those who
have a low bleeding risk (Grade 1B), and we sug-
gest extended anticoagulant therapy in those
with a moderate bleeding risk (Grade 2B).
3.1.4.5. In patients with a second unprovoked
VTE who have a high bleeding risk, we sug-
gest 3 months of anticoagulant therapy over
extended therapy (Grade 2B).
3.1.5. In patients with DVT of the leg and active
cancer, if the risk of bleeding is not high, we
recommend extended anticoagulant therapy
over 3 months of therapy (Grade 1B), and if there
is a high bleeding risk, we suggest extended
anticoagulant therapy (Grade 2B).
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Remarks (3.1.3, 3.1.4, 3.1.4.3): Duration of treatment
of patients with isolated distal DVT refers to patients
in whom a decision has been made to treat with anti-
coagulant therapy; however, it is anticipated that not
all patients who are diagnosed with isolated distal
DVT will be given anticoagulants (see section 2.3). In
all patients who receive extended anticoagulant therapy,
the continuing use of treatment should be reassessed at
periodic intervals (eg, annually).
3.2 Intensity of Anticoagulant Effect
3.2. In patients with DVT of the leg who are
treated with VKA, we recommend a therapeutic
INR range of 2.0 to 3.0 (target INR of 2.5) over
a lower (INR , 2) or higher (INR 3.0-5.0) range
for all treatment durations (Grade 1B).
3.3 Choice of Anticoagulant Regimen for Long-term
Therapy
3.3.1. In patients with DVT of the leg and no can-
cer, we suggest VKA therapy over LMWH for
long-term therapy (Grade 2C). For patients with
DVT and no cancer who are not treated with VKA
therapy, we suggest LMWH over dabigatran or
rivaroxaban for long-term therapy (Grade 2C).
3.3.2. In patients with DVT of the leg and can-
cer, we suggest LMWH over VKA therapy (Grade
2B). In patients with DVT and cancer who are
not treated with LMWH, we suggest VKA over
dabigatran or rivaroxaban for long-term therapy
(Grade 2B).
Remarks (3.3.1-3.3.2): Choice of treatment in patients
with and without cancer is sensitive to the individual
patients tolerance for daily injections, need for labo-
ratory monitoring, and treatment costs. LMWH, rivar-
oxaban, and dabigatran are retained in patients with
renal impairment, whereas this is not a concern with
VKA. Treatment of VTE with dabigatran or rivaroxa-
ban, in addition to being less burdensome to patients,
may prove to be associated with better clinical out-
comes than VKA and LMWH therapy. When these
guidelines were being prepared (October 2011),
postmarketing studies of safety were not available.
Given the paucity of currently available data and that
new data are rapidly emerging, we give a weak rec-
ommendation in favor of VKA and LMWH therapy
over dabigatran and rivaroxaban, and we have not
made any recommendations in favor of one of the
new agents over the other.
3.4 Choice of Anticoagulant Regimen for Extended
Therapy
3.4. In patients with DVT of the leg who receive
extended therapy, we suggest treatment with the
Executive Summary
same anticoagulant chosen for the first 3 months
(Grade 2C).
3.5 Treatment of Patients With Asymptomatic DVT
of the Leg
3.5. In patients who are incidentally found to have
asymptomatic DVT of the leg, we suggest the same
initial and long-term anticoagulation as for compa-
rable patients with symptomatic DVT (Grade 2B).
4.1 Compression Stockings and Bandages to Prevent
PTS
4.1. In patients with acute symptomatic DVT of
the leg, we suggest the use of compression stock-
ings (Grade 2B).
Remarks: Compression stockings should be worn for
2 years, and we suggest beyond that if patients have
developed PTS and find the stockings helpful.
Patients who place a low value on preventing PTS or
a high value on avoiding the inconvenience and dis-
comfort of stockings are likely to decline stockings.
4.2 Physical Treatment of Patients With PTS
4.2.1. In patients with PTS of the leg, we sug-
gest a trial of compression stockings (Grade 2C).
4.2.2. In patients with severe PTS of the leg that
is not adequately relieved by compression stock-
ings, we suggest a trial of an intermittent com-
pression device (Grade 2B).
4.3 Pharmacologic Treatment of Patients With PTS
4.3. In patients with PTS of the leg, we suggest that
venoactive medications (eg, rutosides, defibrot-
ide, and hidrosmin) not be used (Grade 2C).
Remarks: Patients who value the possibility of response
over the risk of side effects may choose to undertake a
therapeutic trial.
5.1 Initial Anticoagulation for Patients With Acute
Pulmonary Embolism (PE)
5.1. In patients with acute PE, we recommend
initial treatment with parenteral anticoagula-
tion (LMWH, fondaparinux, IV UFH, or SC
UFH) over no such initial treatment (Grade 1B).
5.2 Parenteral Anticoagulation Prior to Receipt of the
Results of Diagnostic Work-up for PE
5.2.1. In patients with a high clinical suspicion
of acute PE, we suggest treatment with paren-
teral anticoagulants compared with no treat-
ment while awaiting the results of diagnostic
tests (Grade 2C).
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5.2.2. In patients with an intermediate clinical
suspicion of acute PE, we suggest treatment
with parenteral anticoagulants compared with
no treatment if the results of diagnostic tests
are expected to be delayed for more than 4 h
(Grade 2C).
5.2.3. In patients with a low clinical suspicion of
acute PE, we suggest not treating with paren-
teral anticoagulants while awaiting the results
of diagnostic tests, provided test results are
expected within 24 h (Grade 2C).
5.3 Timing of Initiation of VKA and Associated
Duration of Parenteral Anticoagulant Therapy
5.3. In patients with acute PE, we recommend
early initiation of VKA (eg, same day as paren-
teral therapy is started) over delayed initiation,
and continuation of parenteral anticoagulation
for a minimum of 5 days and until the INR is 2.0
or above for at least 24 h (Grade 1B).
5.4 Choice of Initial Parenteral Anticoagulant Regimen
in Patients With PE
5.4.1. In patients with acute PE, we suggest
LMWH or fondaparinux over IV UFH (Grade 2C
for LMWH; Grade 2B for fondaparinux) and over
SC UFH (Grade 2B for LMWH; Grade 2C for
fondaparinux).
Remarks: Local considerations such as cost, availability,
and familiarity of use dictate the choice between
fondaparinux and LMWH. LMWH and fondaparinux
are retained in patients with renal impairment,
whereas this is not a concern with UFH. In patients
with PE where there is concern about the adequacy
of SC absorption or in patients in whom thrombolytic
therapy is being considered or planned, initial treat-
ment with IV UFH is preferred to use of SC therapies.
5.4.2. In patients with acute PE treated with
LMWH, we suggest once- over twice-daily admin-
istration (Grade 2C).
Remarks: This recommendation only applies when
the approved once-daily regimen uses the same
daily dose as the twice-daily regimen (ie, the once-
daily injection contains double the dose of each
twice-daily injection). It also places value on avoiding
an extra injection per day.
5.5 Early vs Standard Discharge of Patients With
Acute PE
5.5. In patients with low-risk PE and whose
home circumstances are adequate, we suggest
early discharge over standard discharge (eg,
after first 5 days of treatment) (Grade 2B).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 23S
Remarks: Patients who prefer the security of the hos-
pital to the convenience and comfort of home are
likely to choose hospitalization over home treatment.
5.6 Systemic Thrombolytic Therapy for Patients With
PE
5.6.1.1. In patients with acute PE associated
with hypotension (eg, systolic BP , 90 mm Hg)
who do not have a high bleeding risk, we sug-
gest systemically administered thrombolytic
therapy over no such therapy (Grade 2C).
5.6.1.2. In most patients with acute PE not asso-
ciated with hypotension, we recommend against
systemically administered thrombolytic therapy
(Grade 1C).
5.6.1.3. In selected patients with acute PE not
associated with hypotension and with a low bleed-
ing risk whose initial clinical presentation, or
clinical course after starting anticoagulant ther-
apy, suggests a high risk of developing hypoten-
sion, we suggest administration of thrombolytic
therapy (Grade 2C).
5.6.2.1. In patients with acute PE, when a throm-
bolytic agent is used, we suggest short infusion
times (eg, a 2-h infusion) over prolonged infu-
sion times (eg, a 24-h infusion) (Grade 2C).
5.6.2.2. In patients with acute PE when a throm-
bolytic agent is used, we suggest administration
through a peripheral vein over a pulmonary
artery catheter (Grade 2C).
5.7 Catheter-Based Thrombus Removal for the Initial
Treatment of Patients With PE
5.7. In patients with acute PE associated with
hypotension and who have (i) contraindications
to thrombolysis, (ii) failed thrombolysis, or (iii)
shock that is likely to cause death before systemic
thrombolysis can take effect (eg, within hours), if
appropriate expertise and resources are avail-
able, we suggest catheter-assisted thrombus
removal over no such intervention (Grade 2C).
5.8 Surgical Embolectomy for the Initial Treatment
of Patients With PE
5.8. In patients with acute PE associated with
hypotension, we suggest surgical pulmonary
embolectomy over no such intervention if they
have (i) contraindications to thrombolysis, (ii)
failed thrombolysis or catheter-assisted embo-
lectomy, or (iii) shock that is likely to cause
death before thrombolysis can take effect (eg,
within hours), provided surgical expertise and
resources are available (Grade 2C).
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5.9. Vena Cava Filters for the Initial Treatment of
Patients With PE
5.9.1. In patients with acute PE who are treated
with anticoagulants, we recommend against the
use of an IVC filter (Grade 1B).
5.9.2. In patients with acute PE and contraindi-
cation to anticoagulation, we recommend the
use of an IVC filter (Grade 1B).
5.9.3. In patients with acute PE and an IVC
filter inserted as an alternative to anticoagu-
lation, we suggest a conventional course of
anticoagulant therapy if their risk of bleeding
resolves (Grade 2B).
Remarks: We do not consider that a permanent
IVC filter, of itself, is an indication for extended
anticoagulation.
6.0 Long-term Treatment of Patients With PE
6.1. In patients with PE provoked by surgery,
we recommend treatment with anticoagulation
for 3 months over (i) treatment of a shorter
period (Grade 1B), (ii) treatment of a longer time-
limited period (eg, 6 or 12 months) (Grade 1B),
or (iii) extended therapy (Grade 1B regardless of
bleeding risk).
6.2. In patients with PE provoked by a non-
surgical transient risk factor, we recommend
treatment with anticoagulation for 3 months
over (i) treatment of a shorter period (Grade 1B),
(ii) treatment of a longer time-limited period
(eg, 6 or 12 months) (Grade 1B), and (iii) extended
therapy if there is a high bleeding risk (Grade
1B). We suggest treatment with anticoagulation
for 3 months over extended therapy if there is a
low or moderate bleeding risk (Grade 2B).
6.3. In patients with an unprovoked PE, we rec-
ommend treatment with anticoagulation for at
least 3 months over treatment of a shorter dura-
tion (Grade 1B). After 3 months of treatment,
patients with unprovoked PE should be evaluated
for the risk-benefit ratio of extended therapy.
6.3.1. In patients with a first VTE that is an
unprovoked PE and who have a low or mod-
erate bleeding risk, we suggest extended anti-
coagulant therapy over 3 months of therapy
(Grade 2B).
6.3.2. In patients with a first VTE that is an
unprovoked PE and who have a high bleeding
risk, we recommend 3 months of anticoagulant
therapy over extended therapy (Grade 1B).
Executive Summary
6.3.3. In patients with a second unprovoked
VTE, we recommend extended anticoagulant
therapy over 3 months of therapy in those who
have a low bleeding risk (Grade 1B), and we sug-
gest extended anticoagulant therapy in those
with a moderate bleeding risk (Grade 2B).
6.3.4. In patients with a second unprovoked
VTE who have a high bleeding risk, we suggest
3 months of therapy over extended therapy
(Grade 2B).
6.4. In patients with PE and active cancer, if
there is a low or moderate bleeding risk, we
recommend extended anticoagulant therapy
over 3 months of therapy (Grade 1B), and if there
is a high bleeding risk, we suggest extended anti-
coagulant therapy (Grade 2B).
Remarks: In all patients who receive extended anti-
coagulant therapy, the continuing use of treatment
should be reassessed at periodic intervals (eg, annually).
6.5. In patients with PE who are treated with
VKA, we recommend a therapeutic INR range
of 2.0 to 3.0 (target INR of 2.5) over a lower
(INR , 2) or higher (INR 3.0-5.0) range for all
treatment durations (Grade 1B).
6.6. In patients with PE and no cancer, we sug-
gest VKA therapy over LMWH for long-term
therapy (Grade 2C). For patients with PE and no
cancer who are not treated with VKA therapy,
we suggest LMWH over dabigatran or rivaroxa-
ban for long-term therapy (Grade 2C).
6.7. In patients with PE and cancer, we suggest
LMWH over VKA therapy (Grade 2B). In patients
with PE and cancer who are not treated with
LMWH, we suggest VKA over dabigatran or
rivaroxaban for long-term therapy (Grade 2C).
Remarks (6.6-6.7): Choice of treatment in patients
with and without cancer is sensitive to the individual
patients tolerance for daily injections, need for labo-
ratory monitoring, and treatment costs. Treatment of
VTE with dabigatran or rivaroxaban, in addition to
being less burdensome to patients, may prove to be
associated with better clinical outcomes than VKA
and LMWH therapy. When these guidelines were
being prepared (October 2011), postmarketing studies
of safety were not available. Given the paucity of cur-
rently available data and that new data are rapidly
emerging, we give a weak recommendation in favor
of VKA and LMWH therapy over dabigatran and
rivaroxaban, and we have not made any recommen-
dation in favor of one of the new agents over the other.
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6.8. In patients with PE who receive extended
therapy, we suggest treatment with the same
anticoagulant chosen for the first 3 months
(Grade 2C).
6.9. In patients who are incidentally found to
have asymptomatic PE, we suggest the same
initial and long-term anticoagulation as for
comparable patients with symptomatic PE
(Grade 2B).
7.1 Pulmonary Thromboendarterectomy, Anticoagulant
Therapy, and Vena Cava Filter for the Treatment of
Chronic Thromboembolic Pulmonary Hypertension
(CTPH)
7.1.1. In patients with CTPH, we recommend
extended anticoagulation over stopping therapy
(Grade 1B).
7.1.2. In selected patients with CTPH, such as
those with central disease under the care of
an experienced thromboendarterectomy team,
we suggest pulmonary thromboendarterectomy
over no pulmonary thromboendarterectomy
(Grade 2C).
8.1 Treatment of Patients With Superficial Vein
Thrombosis
8.1.1. In patients with superficial vein thrombo-
sis of the lower limb of at least 5 cm in length,
we suggest the use of a prophylactic dose of
fondaparinux or LMWH for 45 days over no
anticoagulation (Grade 2B).
Remarks: Patients who place a high value on avoiding
the inconvenience or cost of anticoagulation and a
low value on avoiding infrequent symptomatic VTE
are likely to decline anticoagulation.
8.1.2. In patients with superficial vein throm-
bosis who are treated with anticoagulation, we
suggest fondaparinux 2.5 mg daily over a pro-
phylactic dose of LMWH (Grade 2C).
9.1 Acute Anticoagulation for Patients With UEDVT
9.1.1. In patients with UEDVT that involves
the axillary or more proximal veins, we recom-
mend acute treatment with parenteral anti-
coagulation (LMWH, fondaparinux, IV UFH,
or SC UFH) over no such acute treatment
(Grade 1B).
9.1.2. In patients with acute UEDVT that
involves the axillary or more proximal veins, we
suggest LMWH or fondaparinux over IV UFH
(Grade 2C) and over SC UFH (Grade 2B).
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9.2 Thrombolytic Therapy for the Initial Treatment
of Patients With UEDVT
9.2.1. In patients with acute UEDVT that
involves the axillary or more proximal veins, we
suggest anticoagulant therapy alone over throm-
bolysis (Grade 2C).
Remarks: Patients who (i) are most likely to benefit
from thrombolysis (see text); (ii) have access to CDT;
(iii) attach a high value to prevention of PTS; and (iv)
attach a lower value to the initial complexity, cost,
and risk of bleeding with thrombolytic therapy are
likely to choose thrombolytic therapy over anticoagu-
lation alone.
9.2.2. In patients with UEDVT who undergo
thrombolysis, we recommend the same inten-
sity and duration of anticoagulant therapy as in
similar patients who do not undergo thromboly-
sis (Grade 1B).
9.3 Long-term Anticoagulation for Patients With
UEDVT
9.3.1. In most patients with UEDVT that is asso-
ciated with a central venous catheter, we sug-
gest that the catheter not be removed if it is
functional and there is an ongoing need for the
catheter (Grade 2C).
9.3.2. In patients with UEDVT that involves
the axillary or more proximal veins, we suggest
a minimum duration of anticoagulation of
3 months over a shorter period (Grade 2B).
Remarks: This recommendation also applies if the
UEDVT was associated with a central venous cath-
eter that was removed shortly after diagnosis.
9.3.3. In patients who have UEDVT that is asso-
ciated with a central venous catheter that is
removed, we recommend 3 months of antico-
agulation over a longer duration of therapy in
patients with no cancer (Grade 1B), and we sug-
gest this in patients with cancer (Grade 2C).
9.3.4. In patients who have UEDVT that is asso-
ciated with a central venous catheter that is not
removed, we recommend that anticoagulation
is continued as long as the central venous cath-
eter remains over stopping after 3 months of
treatment in patients with cancer (Grade 1C),
and we suggest this in patients with no cancer
(Grade 2C).
9.3.5. In patients who have UEDVT that is not
associated with a central venous catheter or with
cancer, we recommend 3 months of anticoagula-
tion over a longer duration of therapy (Grade 1B).
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9.4 Prevention of PTS of the Arm
9.4. In patients with acute symptomatic UEDVT,
we suggest against the use of compression
sleeves or venoactive medications (Grade 2C).
9.5 Treatment of Patients With PTS of the Arm
9.5.1. In patients who have PTS of the arm, we
suggest a trial of compression bandages or
sleeves to reduce symptoms (Grade 2C).
9.5.2. In patients with PTS of the arm, we sug-
gest against treatment with venoactive medica-
tions (Grade 2C).
10.0 Patients With Splanchnic Vein Thrombosis
10.1. In patients with symptomatic splanchnic
vein thrombosis (portal, mesenteric, and/or
splenic vein thromboses), we recommend anti-
coagulation over no anticoagulation (Grade 1B).
10.2. In patients with incidentally detected
splanchnic vein thrombosis (portal, mesen-
teric, and/or splenic vein thromboses), we sug-
gest no anticoagulation over anticoagulation
(Grade 2C).
11.0 Patients With Hepatic Vein Thrombosis
11.1. In patients with symptomatic hepatic vein
thrombosis, we suggest anticoagulation over no
anticoagulation (Grade 2C).
11.2. In patients with incidentally detected
hepatic vein thrombosis, we suggest no antico-
agulation over anticoagulation (Grade 2C).
Treatment and Prevention of
Heparin-Induced Thrombocytopenia
For further details, see Linkins et al.8
2.1 Platelet Count Monitoring Combined With the
4Ts Score for Patients Receiving Heparin/LMWH
2.1.1. For patients receiving heparin in whom
clinicians consider the risk of heparin-induced
thrombocytopenia (HIT) to be . 1%, we suggest
that platelet count monitoring be performed
every 2 or 3 days from day 4 to day 14 (or until
heparin is stopped, whichever occurs first)
(Grade 2C).
2.1.2. For patients receiving heparin in whom
clinicians consider the risk of HIT to be , 1%,
we suggest that platelet counts not be moni-
tored (Grade 2C).
Executive Summary
3.1 Discontinuation of Heparin or Initiation of VKAs
vs Treatment With Nonheparin Anticoagulants
3.1. In patients with HIT complicated by thrombosis
(HITT), we recommend the use of nonheparin
anticoagulants, in particular lepirudin, arga-
troban, and danaparoid, over the further use of
heparin or LMWH or initiation/continuation of
a VKA (Grade 1C).
3.2 Choice of Nonheparin Anticoagulants in Patients
With HITT
3.2.1. In patients with HITT who have normal
renal function, we suggest the use of argatroban
or lepirudin or danaparoid over other nonhepa-
rin anticoagulants (Grade 2C).
Remarks: Other factors not covered by our analysis,
such as drug availability, cost, and ability to monitor the
anticoagulant effect, may influence the choice of agent.
3.2.2. In patients with HITT and renal insuffi-
ciency, we suggest the use of argatroban over
other nonheparin anticoagulants (Grade 2C).
3.3 Platelet Transfusions
3.3 In patients with HIT and severe thrombocy-
topenia, we suggest giving platelet transfusions
only if bleeding or during the performance
of an invasive procedure with a high risk of
bleeding (Grade 2C).
3.4 Starting VKAs Before Platelet Recovery
3.4.1. In patients with strongly suspected or
confirmed HIT, we recommend against starting
VKA until platelets have substantially recovered
(ie, usually to at least 150 3 109/L) over starting
VKA at a lower platelet count and that the VKA
be initially given in low doses (maximum, 5 mg
of warfarin or 6 mg phenprocoumon) over using
higher doses (Grade 1C).
3.4.2. We further suggest that if a VKA has already
been started when a patient is diagnosed with
HIT, vitamin K should be administered (Grade 2C).
Remarks: We place a high value on the prevention
of venous limb gangrene and a low value on the cost
of the additional days of the parental nonheparin
anticoagulant.
3.5 Discontinuation of Thrombin Inhibitor After a
Minimum of 5 Days of Overlap With VKAs
3.5. In patients with confirmed HIT, we recom-
mend that that the VKA be overlapped with a non-
heparin anticoagulant for a minimum of 5 days
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2012 American College of Chest Physicians
and until the INR is within the target range over
shorter periods of overlap and that the INR be
rechecked after the anticoagulant effect of the
nonheparin anticoagulant has resolved (Grade 1C).
4.1 Discontinuation of Heparin or Initiation of VKAs
vs Treatment With Nonheparin Anticoagulants
4.1. In patients with isolated HIT (HIT without
thrombosis), we recommend the use of lepirudin
or argatroban or danaparoid over the further use
of heparin or LMWH or initiation/continuation
of a VKA (Grade 1C).
4.2 Choice of Nonheparin Anticoagulants in Patients
With Isolated HIT
4.2. In patients with isolated HIT (HIT without
thrombosis) who have normal renal function,
we suggest the use of argatroban or lepirudin
or danaparoid over other nonheparin anticoag-
ulants (Grade 2C).
Remarks: Other factors such as drug availability, cost,
and ability to monitor the anticoagulant effect may
influence the choice of agent. The dosing consider-
ations are the same as for patients with HITT (see
section 3.2). For a recommendation on choice of
nonheparin anticoagulants in the setting of renal
insufficiency, see Recommendation 3.2.2.
5.1 Patients Who Require Urgent Cardiac Surgery
5.1.1. In patients with acute HIT (thrombocyto-
penic, HIT antibody positive) or subacute HIT
(platelets recovered but still HIT antibody pos-
itive) who require urgent cardiac surgery, we
suggest the use of bivalirudin over other non-
heparin anticoagulants and over heparin plus
antiplatelet agents (Grade 2C).
5.1.2. In patients with acute HIT who require
nonurgent cardiac surgery, we recommend
delaying the surgery (if possible) until HIT has
resolved and HIT antibodies are negative (see
section 6.1) (Grade 2C).
Remarks: Other factors not covered by our analysis,
such as drug availability, cost, and ability to monitor
the anticoagulant effect may influence the choice of
agent. For recommendations for patients with a past
history of HIT (. 3 months previous) who require
cardiac surgery, see section 6.1.
5.2 Patients Who Require Urgent Percutaneous
Coronary Interventions
5.2. In patients with acute HIT or subacute HIT
who require percutaneous coronary interven-
tions, we suggest the use of bivalirudin (Grade 2B)
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or argatroban (Grade 2C) over other nonheparin
anticoagulants.
Remarks: Other factors, such as drug availability,
cost, and ability to monitor the anticoagulant effect,
may influence the choice of agent.
5.3 Patients Who Require Renal Replacement Therapy
5.3.1. In patients with acute or subacute HIT
who require renal replacement therapy, we
suggest the use of argatroban or danaparoid
over other nonheparin anticoagulants (Grade 2C).
Remarks: We acknowledge that the cost of argatroban
may be prohibitive at some clinical centers. We fur-
ther suggest that if the prothrombotic state of HIT
appears to have resolved (as seen by normalization of
the platelet count), saline flushes during dialysis would
be a reasonable option. This suggestion is based on
the presumed pathogenesis of thrombosis in this
condition and not on the results of clinical trials.
5.3.2. In patients with a past history of HIT who
require ongoing renal replacement therapy
or catheter locking, we suggest the use of
regional citrate over the use of heparin or
LMWH (Grade 2C).
5.4 Pregnant Patients
5.4. In pregnant patients with acute or subacute
HIT, we suggest danaparoid over other non-
heparin anticoagulants (Grade 2C). We suggest
the use of lepirudin or fondaparinux only if
danaparoid is not available (Grade 2C).
Remarks: Other factors, such as drug availability,
cost, and ability to monitor the anticoagulant effect,
may influence the choice of agent.
6.1 Patients With a History of HIT Who Require
Cardiac Surgery
6.1.1. In patients with a history of HIT in whom
heparin antibodies have been shown to be
absent who require cardiac surgery, we suggest
the use of heparin (short-term use only) over
nonheparin anticoagulants (Grade 2C).
6.1.2. In patients with a history of HIT in whom
heparin antibodies are still present who require
cardiac surgery, we suggest the use of nonhepa-
rin anticoagulants (see 5.1.1) over heparin or
LMWH (Grade 2C).
6.2 Patients Who Require PCI
6.2. In patients with a history of HIT in whom
heparin antibodies have been shown to be
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absent who require cardiac catheterization or
percutaneous coronary interventions, the rec-
ommended treatment is the same as 5.2.
6.3 Patients Who Require Prophylaxis or Treatment
of Thrombosis
6.3. In patients with a past history of HIT who
have acute thrombosis (not related to HIT) and
normal renal function, we suggest the use of
fondaparinux at full therapeutic doses until
transition to a VKA can be achieved (Grade 2C).
Antithrombotic Therapy for
Atrial Fibrillation
For further details, see You et al.9
2.1 Patients With Nonrheumatic Atrial Fibrillation
(AF)
2.1.8. For patients with AF, including those with
paroxysmal AF, who are at low risk of stroke
(eg, CHADS2 [congestive heart failure, hyper-
tension, age  75 years, diabetes mellitus, prior
stroke or transient ischemic attack] score 5 0),
we suggest no therapy rather than antithrom-
botic therapy (Grade 2B). For patients who do
choose antithrombotic therapy, we suggest aspi-
rin (75 mg to 325 mg once daily) rather than
oral anticoagulation (Grade 2B) or combination
therapy with aspirin and clopidogrel (Grade 2B).
Remarks: Patients who place an exceptionally high
value on stroke reduction and a low value on avoiding
bleeding and the burden associated with antithrom-
botic therapy are likely to choose antithrombotic
therapy rather than no antithrombotic therapy. Other
factors that may influence the choices above are a
consideration of patient-specific bleeding risk and
the presence of additional risk factors for stroke,
including age 65 to 74 years and female gender, which
have been more consistently validated, and vascular
disease, which has been less well validated (see sec-
tion 2.1.12). The presence of multiple non-CHADS2
risk factors for stroke may favor oral anticoagulation
therapy.
2.1.9. For patients with AF, including those with
paroxysmal AF, who are at intermediate risk of
stroke (eg, CHADS2 score 5 1), we recommend
oral anticoagulation rather than no therapy
(Grade 1B). We suggest oral anticoagulation
rather than aspirin (75 mg to 325 mg once
daily) (Grade 2B) or combination therapy with
aspirin and clopidogrel (Grade 2B). For patients
Executive Summary
who are unsuitable for or choose not to take an
oral anticoagulant (for reasons other than con-
cerns about major bleeding), we suggest com-
bination therapy with aspirin and clopidogrel
rather than aspirin (75 mg to 325 mg once daily)
(Grade 2B).
Remarks: Patients who place an exceptionally high
value on stroke reduction and a low value on avoiding
bleeding and the burden associated with anticoagu-
lant therapy are likely to choose oral anticoagulation
rather than antiplatelet therapy. Other factors that
may influence the choice among antithrombotic
therapies are a consideration of bleeding risk and
the presence of additional risk factors for stroke,
including age 65 to 74 years and female gender,
which have been more consistently validated, and
vascular disease, which has been less well validated
(see section 2.1.12). The presence of multiple addi-
tional non-CHADS2 risk factors for stroke may favor
oral anticoagulation therapy.
2.1.10. For patients with AF, including those with
paroxysmal AF, who are at high risk of stroke
(eg, CHADS2 score 5 2), we recommend oral anti-
coagulation rather than no therapy (Grade 1A),
aspirin (75 mg to 325 mg once daily) (Grade 1B),
or combination therapy with aspirin and clopid-
ogrel (Grade 1B). For patients who are unsuitable
for or choose not to take an oral anticoagulant
(for reasons other than concerns about major
bleeding), we recommend combination therapy
with aspirin and clopidogrel rather than aspirin
(75 mg to 325 mg once daily) (Grade 1B).
2.1.11. For patients with AF, including those
with paroxysmal AF, for recommendations
in favor of oral anticoagulation (including
2.1.9, 2.1.10, and excluding 2.2, 3.1, 3.2, 3.3),
we suggest dabigatran 150 mg twice daily rather
than adjusted-dose VKA therapy (target INR
range, 2.0-3.0) (Grade 2B).
Remarks: Dabigatran is excreted primarily by the
kidney. It has not been studied and is contraindi-
cated in patients with severe renal impairment (esti-
mated creatinine clearance of 30 mL/min or less).
Clinicians should be aware that there is no antidote
for dabigatran.
2.2 Patients With AF and Mitral Stenosis
2.2. For patients with AF and mitral stenosis, we
recommend adjusted-dose VKA therapy (target
INR range, 2.0-3.0) rather than no therapy,
aspirin (75 mg to 325 mg once daily), or combi-
nation therapy with aspirin and clopidogrel (all
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Grade 1B). For patients with AF and mitral ste-
nosis who are unsuitable for or choose not to
take adjusted-dose VKA therapy (for reasons
other than concerns about major bleeding), we
recommend combination therapy with aspirin
and clopidogrel rather than aspirin (75 mg to
325 mg once daily) alone (Grade 1B).
3.1 Patients With AF and Stable Coronary Artery
Disease
3.1. For patients with AF and stable coronary
artery disease (eg, no acute coronary syndrome
within the previous year) and who choose oral
anticoagulation, we suggest adjusted-dose VKA
therapy alone (target international normalized
ratio [INR] range, 2.0-3.0) rather than the com-
bination of adjusted-dose VKA therapy and
aspirin (Grade 2C).
3.2 Patients With AF and Placement of an Intracoro-
nary Stent
3.2. For patients with AF at high risk of stroke
(eg, CHADS2 score of 2 or greater) during the
first month after placement of a bare-metal
stent or the first 3 to 6 months after place-
ment of a drug-eluting stent, we suggest triple
therapy (eg, VKA therapy, aspirin, and clopid-
ogrel) rather than dual antiplatelet therapy
(eg, aspirin and clopidogrel) (Grade 2C). After
this initial period of triple therapy, we suggest
a VKA (INR 2.0-3.0) plus a single antiplatelet
drug rather than VKA alone (Grade 2C). At
12 months after intracoronary stent place-
ment, antithrombotic therapy is suggested as
for patients with AF and stable coronary artery
disease (see section 3.1).
For patients with AF at low to intermediate risk
of stroke (eg, CHADS2 score of 0 or 1) during
the first 12 months after placement of an intra-
coronary stent (bare metal or drug eluting), we
suggest dual antiplatelet therapy rather than
triple therapy (Grade 2C). At 12 months after
intracoronary stent placement, antithrombotic
therapy is suggested as for patients with AF and
stable coronary artery disease (see section 3.1).
Remarks: Patients who place an exceptionally high
value on stroke reduction and a low value on avoid-
ing bleeding and the burden associated with antico-
agulant therapy are likely to choose triple therapy
rather than dual antiplatelet therapy. Other factors
that may influence this choice are a consideration of
bleeding risk and the presence of additional non-
CHADS2 risk factors for stroke (see section 2.1.12).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 29S
3.3 Patients With AF and ACS Who Do Not Undergo
Intracoronary Stent Placement
3.3. For patients with AF at intermediate to high
risk of stroke (eg, CHADS2 score of 1 or greater)
who experience an acute coronary syndrome
and do not undergo intracoronary stent place-
ment, we suggest for the first 12 months, adjust-
ed-dose VKA therapy (INR 2.0-3.0) plus single
antiplatelet therapy rather than dual anti-
platelet therapy (eg, aspirin and clopidogrel) or
triple therapy (eg, warfarin, aspirin, and clo-
pidogrel) (Grade 2C). After the first 12 months,
antithrombotic therapy is suggested as for
patients with AF and stable coronary artery
disease (see section 3.1).
For patients with AF at low risk of stroke (eg,
CHADS2 score of 0), we suggest dual antiplate-
let therapy (eg, aspirin and clopidogrel) rather
than adjusted-dose VKA therapy (INR 2.0-3.0)
plus single antiplatelet therapy or triple therapy
(eg, warfarin, aspirin, and clopidogrel) (Grade
2C). After the first 12 months, antithrombotic
therapy is suggested as for patients with AF and
stable coronary artery disease (see section 3.1).
Remarks: Patients who place an exceptionally high
value on stroke reduction and a low value on avoiding
bleeding and the burden associated with anticoagu-
lant therapy are likely to choose adjusted-dose VKA
therapy plus single antiplatelet therapy rather than
dual antiplatelet therapy. Other factors that may
influence this choice are a consideration of bleeding
risk and the presence of additional non-CHADS2 risk
factors for stroke (see section 2.1.12).
3.4 Patients With AF Managed by a Rhythm Control
Strategy
3.4. For patients with AF being managed with a
rhythm control strategy (pharmacologic or cath-
eter ablation), we suggest that antithrombotic
therapy decisions follow the general risk-based
recommendations for patients with AF in sec-
tion 2.1, regardless of the apparent persistence
of normal sinus rhythm (Grade 2C).
3.5 Patients With Atrial Flutter
3.5. For patients with atrial flutter, we suggest
that antithrombotic therapy decisions follow
the same risk-based recommendations as for
AF.
4.1 Patients Undergoing Elective Cardioversion of AF
4.1.1. For patients with AF of greater than
48 h or unknown duration undergoing elective
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electrical or pharmacologic cardioversion,
we recommend therapeutic anticoagulation
(adjusted-dose VKA therapy, target INR range
2.0-3.0, low-molecular-weight heparin at full
venous thromboembolism treatment doses, or
dabigatran) for at least 3 weeks before cardio-
version or a transesophageal echocardiography
(TEE)-guided approach with abbreviated anti-
coagulation before cardioversion rather than
no anticoagulation (Grade 1B). We recommend
therapeutic anticoagulation for at least 4 weeks
after successful cardioversion to sinus rhythm
rather than no anticoagulation, regardless of
the baseline risk of stroke (Grade 1B). Decisions
about anticoagulation beyond 4 weeks should
be made in accordance with our risk-based rec-
ommendations for long-term antithrombotic
therapy in section 2.1.
4.1.2. For patients with AF of documented
duration of 48 h or less undergoing elective
cardioversion (electrical or pharmacologic), we
suggest starting anticoagulation at presentation
(low-molecular-weight heparin or unfraction-
ated heparin at full venous thromboembolism
treatment doses) and proceeding to cardio-
version rather than delaying cardioversion
for 3 weeks of therapeutic anticoagulation or
a TEE-guided approach (Grade 2C). After suc-
cessful cardioversion to sinus rhythm, we rec-
ommend therapeutic anticoagulation for at
least 4 weeks rather than no anticoagulation,
regardless of baseline stroke risk (Grade 2C).
Decisions about long-term anticoagulation
after cardioversion should be made in accor-
dance with our risk-based recommendations
for long-term antithrombotic therapy in sec-
tion 2.1.
4.2 Patients Undergoing Urgent Cardioversion for
Hemodynamically Unstable AF
4.2. For patients with AF and hemodynamic
instability undergoing urgent cardioversion
(electrical or pharmacologic), we suggest that
therapeutic-dose parenteral anticoagulation
be started before cardioversion, if possible
(Grade 2C), but that initiation of anticoagula-
tion must not delay any emergency intervention
(Grade 2C). After successful cardioversion to
sinus rhythm, we suggest therapeutic anticoag-
ulation for at least 4 weeks after successful
cardioversion to sinus rhythm rather than no
anticoagulation, regardless of baseline stroke
risk (Grade 2C). Decisions about anticoagula-
tion beyond 4 weeks should be made in accor-
dance with our risk-based recommendations
Executive Summary
for long-term antithrombotic therapy in sec-
tion 2.1.
4.3 Patients Undergoing Elective or Urgent
Cardioversion for Atrial Flutter
4.3. For patients with atrial flutter undergoing
elective or urgent pharmacologic or electrical
cardioversion, we suggest that the same
approach to thromboprophylaxis be used as
for patients with atrial fibrillation undergoing
cardioversion.
Antithrombotic and Thrombolytic
Therapy for Valvular Disease
For further details, see Whitlock et al.10
2.0 Patients With Rheumatic Mitral Valve Disease
2.0.1. In patients with rheumatic mitral valve
disease and normal sinus rhythm with a left
atrial diameter , 55 mm we suggest not using
antiplatelet or VKA therapy (Grade 2C).
2.0.2. In patients with rheumatic mitral valve
disease and normal sinus rhythm with a left
atrial diameter . 55 mm, we suggest VKA ther-
apy (target INR, 2.5; range, 2.0-3.0) over no
VKA therapy or antiplatelet (Grade 2C).
2.0.3. For patients with rheumatic mitral valve
disease complicated by the presence of left
atrial thrombus, we recommend VKA therapy
(target INR, 2.5; range, 2.0-3.0) over no VKA
therapy (Grade 1A).
2.0.4. For patients with rheumatic mitral valve
disease complicated singly or in combination by
the presence of atrial fibrillation or previous
systemic embolism, we recommend VKA therapy
(target INR, 2.5; range, 2.0-3.0) over no VKA
therapy (Grade 1A).
2.1 Patients With Rheumatic Mitral Valve Disease
Undergoing Percutaneous Mitral Balloon Valvotomy
(PMBV)
2.1.1. For patients being considered for PMBV
with preprocedural TEE showing left atrial
thrombus, we recommend postponement of
PMBV and that VKA therapy (target INR, 3.0;
range, 2.5-3.5) be administered until thrombus
resolution is documented by repeat TEE over
no VKA therapy (Grade 1A).
2.1.2. For patients being considered for PMBV
with preprocedural TEE showing left atrial
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thrombus, if the left atrial thrombus does not
resolve with VKA therapy, we recommend that
PMBV not be performed (Grade 1A).
6.2.1. In patients with asymptomatic patent
foramen ovale (PFO) or atrial septal aneurysm, we
suggest against antithrombotic therapy (Grade 2C).
6.2 Patients With PFO and Atrial Septal Aneurysm
6.2.2. In patients with cryptogenic stroke and
PFO or atrial septal aneurysm, we recom-
mend aspirin (50-100 mg/d) over no aspirin
(Grade 1A).
6.2.3. In patients with cryptogenic stroke and
PFO or atrial septal aneurysm, who experience
recurrent events despite aspirin therapy, we
suggest treatment with VKA therapy (target
INR, 2.5; range, 2.0-3.0) and consideration of
device closure over aspirin therapy (Grade 2C).
6.2.4. In patients with cryptogenic stroke and
PFO, with evidence of DVT, we recommend
VKA therapy for 3 months (target INR, 2.5;
range, 2.0-3.0) (Grade 1B) and consideration of
device closure over no VKA therapy or aspirin
therapy (Grade 2C).
7.1 Role of Anticoagulants and Antiplatelet Agents in
Patients With Native Valve Endocarditis
7.1.1. In patients with infective endocarditis
(IE), we recommend against routine anticoagu-
lant therapy, unless a separate indication exists
(Grade 1C).
7.1.2. In patients with IE, we recommend
against routine antiplatelet therapy, unless a
separate indication exists (Grade 1B).
7.2 Role of Anticoagulants in Patients With Prosthetic
Valve Endocarditis
7.2. In patients on VKA for a prosthetic valve
who develop IE, we suggest VKA be discontin-
ued at the time of initial presentation until it
is clear that invasive procedures will not be
required and the patient has stabilized without
signs of CNS involvement. When the patient is
deemed stable without contraindications or neu-
rologic complications, we suggest reinstitution
of VKA therapy (Grade 2C).
7.3 Patients With Nonbacterial Thrombotic Endocarditis
7.3. In patients with nonbacterial thrombotic
endocarditis and systemic or pulmonary emboli,
we suggest treatment with full-dose IV UFH or
SC LMWH over no anticoagulation (Grade 2C).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 31S
8.2 Antithrombotic Therapy in the First 3 Months
After Surgery
8.2.1. In patients with aortic bioprosthetic
valves, who are in sinus rhythm and have no
other indication for VKA therapy, we suggest
aspirin (50-100 mg/d) over VKA therapy in the
first 3 months (Grade 2C).
8.2.2. In patients with transcatheter aortic bio-
prosthetic valves, we suggest aspirin (50-100 mg/d)
plus clopidogrel (75 mg/d) over VKA therapy
and over no antiplatelet therapy in the first
3 months (Grade 2C).
8.2.3. In patients with a bioprosthetic valve in
the mitral position, we suggest VKA therapy
(target INR, 2.5; range, 2.0-3.0) over no VKA
therapy for the first 3 months after valve inser-
tion (Grade 2C).
8.3 Long-term Antithrombotic Therapy for Patients
With Bioprosthetic Valves
8.3. In patients with bioprosthetic valves in nor-
mal sinus rhythm, we suggest aspirin therapy
over no aspirin therapy after 3 months postop-
erative (Grade 2C).
9.1 Early Postoperative Bridging to Intermediate/
Long-term Therapy (Postoperative Day 0 to 5)
9.1. In patients with mechanical heart valves, we
suggest bridging with unfractionated heparin
(UFH, prophylactic dose) or LMWH (prophy-
lactic or therapeutic dose) over IV therapeutic
UFH until stable on VKA therapy (Grade 2C).
9.2 Long-term Antithrombotic Therapy for Patients
With Mechanical Valves
9.2. In patients with mechanical heart valves,
we recommend VKA therapy over no VKA
therapy for long-term management (Grade 1B).
9.3 Intensity of VKA Therapy for Patients With
Mechanical Aortic Valve Prostheses
9.3.1. In patients with a mechanical aortic valve,
we suggest VKA therapy with a target of 2.5
(range, 2.0-3.0) over lower targets (Grade 2C).
9.3.2. In patients with a mechanical aortic
valve, we recommend VKA therapy with a tar-
get of 2.5 (range 2.0-3.0) over higher targets
(Grade 1B).
9.4 Intensity of VKA Therapy for Patients With
Mechanical Mitral Valve Prostheses
9.4. In patients with a mechanical mitral valve,
we suggest VKA therapy with a target of
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3.0 (range, 2.5-3.5) over lower INR targets
(Grade 2C).
9.5 Intensity of VKA Therapy in Patients With Double
Mechanical Valve or With Additional Risk Factors
9.5. In patients with mechanical heart valves in
both the aortic and mitral position, we suggest
target INR 3.0 (range 2.5-3.5) over target INR
2.5 (range 2.0-3.0) (Grade 2C).
9.6 Antiplaelet Agent in Addition to VKA Therapy for
Patients With Mechanical Aortic or Mitral Valve
Prostheses
9.6. In patients with a mechanical mitral or aor-
tic valve at low risk of bleeding, we suggest add-
ing over not adding an antiplatelet agent such
as low-dose aspirin (50-100 mg/d) to the VKA
therapy (Grade 1B).
Remarks: Caution should be used in patients at
increased bleeding risk, such as history of GI bleeding.
9.7 Antiplatelet Agent Therapy Instead of VKA Therapy
9.7. For patients with mechanical aortic or
mitral valves we recommend VKA over anti-
platelet agents (Grade 1B).
10.1 Antithrombotic Therapy After Mitral Valve
Repair
10.1. In patients undergoing mitral valve repair
with a prosthetic band in normal sinus rhythm,
we suggest the use of antiplatelet therapy for
the first 3 months over VKA therapy (Grade 2C).
10.2 Patients Undergoing Aortic Valve Repair
10.2. In patients undergoing aortic valve repair,
we suggest aspirin at 50 to 100 mg/d over VKA
therapy (Grade 2C).
11.1 Patients With Right-Sided Prosthetic Valve
Thrombosis
11.1. For patients with right-sided prosthetic
valve thrombosis (PVT), in the absence of con-
traindications we suggest administration of
fibrinolytic therapy over surgical intervention
(Grade 2C).
11.2 Patients With Left-Sided Prosthetic Valve
Thrombosis
11.2.1. For patients with left-sided PVT and large
thrombus area ( 0.8 cm2), we suggest early sur-
gery over fibrinolytic therapy (Grade 2C). If con-
traindications to surgery exist, we suggest the
use of fibrinolytic therapy (Grade 2C).
11.2.2. For patients with left-sided PVT and
small thrombus area (, 0.8 cm2), we suggest
Executive Summary
administration of fibrinolytic therapy over
surgery. For very small, nonobstructive thrombus
we suggest IV UFH accompanied by serial Dopp-
ler echocardiography to document thrombus
resolution or improvement over other alterna-
tives (Grade 2C).
Antithrombotic and Thrombolytic
Therapy for Ischemic Stroke
For further details, see Lansberg et al.11
2.1 IV Recombinant Tissue Plasminogen Activator
(r-tPA) for Patients With Acute Ischemic Stroke
2.1.1. In patients with acute ischemic stroke in
whom treatment can be initiated within 3 h of
symptom onset, we recommend IV r-tPA over
no IV r-tPA (Grade 1A).
2.1.2. In patients with acute ischemic stroke in
whom treatment can be initiated within 4.5 but
not within 3 h of symptom onset, we suggest IV
r-tPA over no IV r-tPA (Grade 2C).
2.1.3. In patients with acute ischemic stroke in
whom treatment cannot be initiated within 4.5 h
of symptom onset, we recommend against IV
r-tPA (Grade 1B).
2.2 Intraarterial Thrombolysis in Patients With
Acute Ischemic Stroke
2.2.1. In patients with acute ischemic stroke due
to proximal cerebral artery occlusions who do
not meet eligibility criteria for treatment with
IV r-tPA, we suggest intraarterial (IA) r-tPA
initiated within 6 h of symptom onset over no
IA r-tPA (Grade 2C).
2.2.2. In patients with acute ischemic stroke we
suggest IV r-tPA over the combination IV/IA
r-tPA (Grade 2C).
Remarks: Carefully selected patients who value the
uncertain benefits of combination IV/IA throm-
bolysis higher than the associated risks may choose
this intervention. Patients who prefer to avoid risk in
the setting of uncertain benefits are more likely to
choose IV r-tPA alone.
2.3 Mechanical Thrombectomy in Patients With
Acute Ischemic Stroke
2.3. In patients with acute ischemic stroke, we
suggest against the use of mechanical throm-
bectomy (Grade 2C).
Remarks: Carefully selected patients who value
the uncertain benefit of mechanical thrombectomy
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2012 American College of Chest Physicians
higher than the associated risks may choose this
intervention.
2.4 Aspirin in Patients With Acute Ischemic Stroke
2.4. In patients with acute ischemic stroke or
transient ischemic attack (TIA), we recommend
early (within 48 h) aspirin therapy at a dose of
160 to 325 mg over no aspirin therapy (Grade 1A).
2.5 Anticoagulation in Patients With Acute Ischemic
Stroke
2.5. In patients with acute ischemic stroke or
TIA, we recommend early (within 48 h) aspirin
therapy with an initial dose of 160 to 325 mg
over therapeutic parenteral anticoagulation
(Grade 1A).
3.1 VTE Prevention in Patients With Ischemic Stroke
3.1.1. In patients with acute ischemic stroke
and restricted mobility, we suggest prophylactic-
dose SC UFH or LMWH or intermittent pneu-
matic compression devices over no prophylaxis
(Grade 2B).
3.1.2. In patients with acute ischemic stroke and
restricted mobility, we suggest prophylactic-dose
LMWH over prophylactic-dose UFH (Grade 2B).
3.1.3. In patients with acute stroke and restricted
mobility, we suggest against elastic compression
stockings (Grade 2B).
Remarks: Pharmacologic and mechanical prophy-
laxis should be initiated as early as possible and should
be continued throughout the hospital stay or until
the patient has regained mobility. Mechanical devices
should be temporarily removed as often as needed
to allow for early mobilization and screening for
skin complications.
Combining pharmacologic therapy with intermittent
pneumatic compression devices may yield additional
benefit in prevention of VTEs compared with either
method used alone.
3.2 VTE Prevention in Patients With Hemorrhagic
Stroke
3.2.1. In patients with acute primary intracere-
bral hemorrhage and restricted mobility, we
suggest prophylactic-dose SC heparin (UFH or
LMWH) started between days 2 and 4 or inter-
mittent pneumatic compression devices over
no prophylaxis (Grade 2C).
3.2.2. In patients with acute primary intrac-
erebral hemorrhage and restricted mobility,
we suggest prophylactic-dose LMWH over
prophylactic-dose UFH (Grade 2B).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 33S
3.2.3. In patients with primary intracerebral
hemorrhage and restricted mobility, we suggest
against elastic compression stockings (Grade 2B).
Remarks: Patients who prefer to avoid a theoreti-
cally increased risk of rebleeding with heparin
would favor mechanical prophylaxis with intermit-
tent pneumatic compression devices over pharmaco-
logic prophylaxis.
Combining pharmacologic therapy with intermit-
tent pneumatic compression devices may yield addi-
tional benefit in prevention of VTEs compared with
either method used alone.
4.1 Antithrombotic Therapy for the Secondary
Prevention of Noncardioembolic Stroke
4.1.1. In patients with a history of noncardioem-
bolic ischemic stroke or TIA, we recommend
long-term treatment with aspirin (75-100 mg once
daily), clopidogrel (75 mg once daily), aspirin/
extended-release dipyridamole (25 mg/200 mg
bid), or cilostazol (100 mg bid) over no anti-
platelet therapy (Grade 1A), oral anticoagulants
(Grade 1B), the combination of clopidogrel plus
aspirin (Grade 1B), or triflusal (grade 2B).
4.1.2. Of the recommended antiplatelet regimens,
we suggest clopidogrel or aspirin/extended-
release dipyridamole over aspirin (Grade 2B) or
cilostazol (Grade 2C).
Remarks: With long-term use (. 5 y), the benefit of
clopidogrel over aspirin in preventing major vascular
events may be offset by a reduction in cancer-related
mortality with regimens that contain aspirin.
4.2 Antithrombotic Therapy for the Secondary
Prevention of Cardioembolic Stroke
4.2.1. In patients with a history of ischemic
stroke or TIA and AF, including paroxysmal
AF, we recommend oral anticoagulation over
no antithrombotic therapy (Grade 1A), aspirin
(Grade 1B), or combination therapy with aspirin
and clopidogrel (Grade 1B).
4.2.2. In patients with a history of ischemic
stroke or TIA and atrial fibrillation, including
paroxysmal AF, we suggest oral anticoagulation
with dabigatran 150 mg bid over adjusted-dose
VKA therapy (target range, 2.0-3.0) (Grade 2B).
4.2.3. In patients with a history of ischemic
stroke or TIA and atrial fibrillation, including
paroxysmal AF, who are unsuitable for or choose
not to take an oral anticoagulant (for reasons
other than concerns about major bleeding), we
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2012 American College of Chest Physicians
recommend combination therapy with aspirin
and clopidogrel over aspirin (Grade 1B).
Remarks: Patients should be treated (ie, bridged)
with aspirin until anticoagulation has reached a
therapeutic level.
Oral anticoagulation should generally be initiated
within 1 to 2 weeks after stroke onset. Earlier anti-
coagulation can be considered for patients at low
risk of bleeding complications (eg, those with a small
infarct burden and no evidence of hemorrhage on
brain imaging). Delaying anticoagulation should be
considered for patients at high risk of hemorrhagic
complications (eg, those with extensive infarct bur-
den or evidence of significant hemorrhagic transfor-
mation on brain imaging).
Dabigatran is excreted primarily by the kidney. It has
not been studied and is contraindicated in patients
with severe renal impairment (estimated creatinine
clearance of 30 mL/min or less).
4.3 Antithrombotic Therapy for Stroke Prevention in
Patients With a History of Intracerebral Hemorrhage
(ICH)
4.3. In patients with a history of a symptomatic
primary ICH, we suggest against the long-term
use of antithrombotic therapy for the preven-
tion of ischemic stroke (Grade 2C).
Remarks: Patients who might benefit from antithrom-
botic therapy are those at relatively low risk of recur-
rent ICH (eg, with deep hemorrhages) and relatively
high risk (. 7% per year) of thromboembolic events
(eg, with mechanical heart valves or CHADS2 (Con-
gestive heart failure, Hypertension, Age . 75, Diabetes
mellitus, Stroke or TIA) score . 4 points).
5.1 Anticoagulation for Patients With Symptomatic
Cerebral Venous Sinus Thrombosis
5.1. In patients with cerebral venous sinus
thrombosis, we suggest anticoagulation over
no anticoagulant therapy during the acute and
chronic phases (Grade 2C).
Remarks: Patients with a history of ICH who might
benefit from antithrombotic therapy are those at rel-
atively low risk of recurrent ICH (eg, with deep hem-
orrhages) and relatively high risk (. 7% per year) of
cardiac thromboembolic events (eg, with mechanical
heart valves or CHADS2 score . 4 points).
The Primary and Secondary Prevention
of Cardiovascular Disease
For further details, see Vandvik et al.12
Executive Summary
2.0 Primary Prevention of Cardiovascular Disease
2.1. For persons aged 50 years or older without
symptomatic cardiovascular disease, we suggest
low-dose aspirin 75 to 100 mg daily over no
aspirin therapy (Grade 2B).
Remarks: Aspirin slightly reduces total mortality
regardless of cardiovascular risk profile if taken over
10 years. In people at moderate to high risk of cardio-
vascular events, the reduction in myocardial infarc-
tion (MI) is closely balanced with an increase in major
bleeds. Whatever their risk status, people who are
averse to taking medication over a prolonged time period
for very small benefits will be disinclined to use aspirin
for primary prophylaxis. Individuals who value pre-
venting an MI substantially higher than avoiding a GI
bleed will be, if they are in the moderate or high car-
diovascular risk group, more likely to choose aspirin.
3.1 Choice of Long-term Antithrombotic Therapy in
Patients With Established Coronary Artery Disease (CAD)
3.1.1-3.1.5. For patients with established coronary
artery disease (CAD), defined as patients 1-year
post-acute coronary syndrome (ACS), with prior
revascularization, coronary stenoses . 50% by
coronary angiogram, and/or evidence for cardiac
ischemia on diagnostic testing, (including patients
after the first year post-ACS and/or with prior
coronary artery bypass graft [CABG] surgery):
We recommend long-term single antiplate-
let therapy with aspirin 75 to 100 mg daily
or clopidogrel 75 mg daily over no anti-
platelet therapy (Grade 1A).
We suggest single over dual antiplatelet ther-
apy with aspirin plus clopidogrel (Grade 2B).
3.2 Choice of Antithrombotic Therapy Following ACS
3.2.1-3.2.5. For patients in the first year after an
ACS who have not undergone percutaneous
coronary intervention (PCI):
We recommend dual antiplatelet therapy
(ticagrelor 90 mg twice daily plus low-dose
aspirin 75-100 mg daily or clopidogrel 75 mg
daily plus low-dose aspirin 75-100 mg daily)
over single antiplatelet therapy (Grade 1B).
We suggest ticagrelor 90 mg daily plus low-
dose aspirin over clopidogrel 75 mg daily
plus low-dose aspirin (Grade 2B).
For patients in the first year after an ACS who
have undergone PCI with stent placement:
We recommend dual antiplatelet therapy
(ticagrelor 90 mg twice daily plus low-dose
aspirin 75-100 mg daily, clopidogrel 75 mg
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daily plus low-dose aspirin, or prasugrel
10 mg daily plus low-dose aspirin over
single antiplatelet therapy) (Grade 1B).
Remarks: Evidence suggests that prasugrel results in
no benefit net harm in patients with a body weight
of , 60 kg, age . 75 years, or with a previous stroke/
transient ischemic attack.
We suggest ticagrelor 90 mg twice daily
plus low-dose aspirin over clopidogrel
75 mg daily plus low-dose aspirin (Grade 2B).
For patients with ACS who undergo PCI with
stent placement, we refer to sections 4.3.1 to
4.3.5 for recommendations concerning minimum
and prolonged duration of treatment.
3.2.6-3.2.7. For patients with anterior MI and left
ventricular (LV) thrombus, or at high risk for LV
thrombus (ejection fraction , 40%, anteroapical
wall motion abnormality), who do not undergo
stenting:
We recommend warfarin (INR 2.0-3.0) plus
low-dose aspirin 75 to 100 mg daily over
single antiplatelet therapy or dual antiplatelet
therapy for the first 3 months (Grade 1B).
Thereafter, we recommend discontinuation
of warfarin and continuation of dual anti-
platelet therapy for up to 12 months as per
the ACS recommendations (see recommen-
dations 3.2.1-3.2.5). After 12 months, single
antiplatelet therapy is recommended as
per the established CAD recommendations
(see recommendations 3.1.1-3.1.5).
For patients with anterior MI and LV thrombus,
or at high risk for LV thrombus (ejection frac-
tion , 40%, anteroapical wall motion abnor-
mality), who undergo bare-metal stent (BMS)
placement:
We suggest triple therapy (warfarin [INR
2.0-3.0], low-dose aspirin, clopidogrel 75 mg
daily) for 1 month over dual antiplatelet
therapy (Grade 2C).
We suggest warfarin (INR 2.0-3.0) and single
antiplatelet therapy for the second and third
month post-BMS over alternative regimens
and alternative time frames for warfarin
use (Grade 2C). Thereafter, we recommend
discontinuation of warfarin and use of dual
antiplatelet therapy for up to 12 months as
per the ACS recommendations (see recom-
mendations 3.2.1-3.2.5). After 12 months,
antiplatelet therapy is recommended as
per the established CAD recommendations
(see recommendations 3.1.1-3.1.5).
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For patients with anterior MI and LV thrombus,
or at high risk for LV thrombus (ejection frac-
tion , 40%, anteroapical wall motion abnor-
mality) who undergo drug-eluting stent (DES)
placement:
We suggest triple therapy (warfarin INR
2.0-3.0, low-dose aspirin, clopidogrel 75 mg
daily) for 3 to 6 months over alternative
regimens and alternative durations of war-
farin therapy (Grade 2C). Thereafter, we
recommend discontinuation of warfarin and
continuation of dual antiplatelet therapy for
up to 12 months as per the ACS recommen-
dations (see recommendations 3.2.1-3.2.5).
After 12 months, antiplatelet therapy is
recommended as per the established CAD
recommendations (see recommendations
3.1.1-3.1.5).
4.0 Antithrombotic Therapy Following Elective PCI
4.1.1-4.3.5. For patients who have undergone
elective PCI with placement of BMS:
For the first month, we recommend dual
antiplatelet therapy with aspirin 75 to
325 mg daily and clopidogrel 75 mg daily
over single antiplatelet therapy (Grade 1A).
For the subsequent 11 months, we suggest
dual antiplatelet therapy with combination
of low-dose aspirin 75 to 100 mg daily and
clopidogrel 75 mg daily over single anti-
platelet therapy (Grade 2C).
After 12 months, we recommend single
antiplatelet therapy over continuation of
dual antiplatelet therapy (Grade 1B).
For patients who have undergone elective PCI
with placement of DES:
For the first 3 to 6 months, we recommend
dual antiplatelet therapy with aspirin 75 to
325 mg daily and clopidogrel 75 mg daily
over single antiplatelet therapy (Grade 1A).
Remarks: Absolute minimum duration will vary based
on stent type (in general, 3 months for -limus stents
and 6 months for -taxel stents).
After 3 to 6 months, we suggest continua-
tion of dual antiplatelet therapy with low-
dose aspirin 75 to 100 mg and clopidogrel
(75 mg daily) until 12 months over single
antiplatelet therapy (Grade 2C).
After 12 months, we recommend single anti-
platelet therapy over continuation of dual
antiplatelet therapy (Grade 1B). Single anti-
platelet therapy thereafter is recommended
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as per the established CAD recommenda-
tions (see recommendations 3.1.1-3.1.5).
For patients who have undergone elective BMS
or DES stent placement:
We recommend using low-dose aspirin 75
to 100 mg daily and clopidogrel 75 mg daily
alone rather than cilostazol in addition to
these drugs (Grade 1B).
We suggest aspirin 75 to 100 mg daily or
clopidogrel 75 mg daily as part of dual anti-
platelet therapy rather than the use of
either drug with cilostazol (Grade 1B).
We suggest cilostazol 100 mg twice daily as
substitute for either low-dose aspirin 75 to
100 mg daily or clopidogrel 75 mg daily
as part of a dual antiplatelet regimen in
patients with an allergy or intolerance of
either drug class (Grade 2C).
For patients with CAD undergoing elective PCI
but no stent placement:
We suggest for the first month dual antiplate-
let therapy with aspirin 75 to 325 mg daily
and clopidogrel 75 mg daily over single anti-
platelet therapy (Grade 2C). Single antiplate-
let therapy thereafter is recommended as
per the established CAD recommendations
(see recommendations 3.1.1-3.1.5).
5.0 Antithrombotic Therapy in Patients With Systolic
LV Dysfunction
5.1-5.3. For patients with systolic LV dysfunc-
tion without established CAD and no LV throm-
bus, we suggest not to use antiplatelet therapy
or warfarin (Grade 2C).
Remarks: Patients who place a high value on an
uncertain reduction in stroke and a low value on
avoiding an increased risk of GI bleeding are likely to
choose to use warfarin.
For patients with systolic LV dysfunction with-
out established CAD with identified acute
LV thrombus (eg, Takotsubo cardiomyopathy),
we suggest moderate-intensity warfarin (INR
2.0-3.0) for at least 3 months (Grade 2C).
For patients with systolic LV dysfunction and
established CAD, recommendations are as per
the established CAD recommendations (see rec-
ommendations 3.1.1-3.1.5).
Antithrombotic Therapy in
Peripheral Artery Disease
For further details, see Alonso-Coello et al.13
Executive Summary
2.0 Primary Prevention of Cardiovascular Events
in Patients with Asymptomatic PAD
2.1. For persons with asymptomatic peripheral
arterial disease (PAD), we suggest aspirin 75 to
100 mg daily over no aspirin therapy (Grade 2B).
Remarks: Aspirin slightly reduces total mortality
regardless of cardiovascular risk profile if taken over
10 years. In people at moderate to high risk of cardio-
vascular events, the reduction in myocardial infarc-
tion (MI) is closely balanced with an increase in major
bleeds. Whatever their risk status, people who are
averse to taking medication over a prolonged time
period for very small benefits will be disinclined to
use aspirin for primary prophylaxis. Individuals who
value preventing an MI substantially higher than
avoiding a GI bleed, if they are in the moderate or
high cardiovascular risk group, will be more likely to
choose aspirin.
3.0 Secondary Prevention of Cardiovascular Events
in Patients with Symptomatic PAD
3.1-3.4. For secondary prevention patients with
symptomatic PAD, we recommend one of the
two following antithrombotic regimens to be
continued long term over no antithrombotic
treatment: aspirin 75 to 100 mg daily or clopid-
ogrel 75 mg daily (all Grade 1A). We suggest not
to use dual antiplatelet therapy with aspirin plus
clopidogrel (Grade 2B). We recommend not to
use an antiplatelet agent with moderate-inten-
sity warfarin (Grade 1B).
4.0 Antithrombotic Therapy for the Management of
Patients with Claudication
4.1-4.4. For patients with intermittent claudica-
tion refractory to exercise therapy (and smoking
cessation), we suggest the use of cilostazol in
addition to previously recommended antithrom-
botic therapies (aspirin 75-100 mg daily or
clopidogrel 75 mg daily) (Grade 2C); we suggest
against the use of pentoxifylline, heparinoids,
or prostanoids (Grade 2C).
5.0 Patients With Critical Limb Ischemia
5.1. For patients with symptomatic PAD and
critical leg ischemia/rest pain who are not can-
didates for vascular intervention, we suggest
the use of prostanoids in addition to previously
recommended antithrombotic therapies (aspi-
rin 75-100 mg daily or clopidogrel 75 mg daily)
(Grade 2C).
Values and preferences: Patients who do not value
uncertain relief of rest pain and ulcer healing greater
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than avoidance of a high likelihood of drug-related
side effects will be disinclined to take prostanoids.
6.0 Acute Limb Ischemia
6.1-6.3. In patients with acute limb ischemia
due to arterial emboli or thrombosis, we sug-
gest immediate systemic anticoagulation with
unfractionated heparin over no anticoagulation
(Grade 2C); we suggest reperfusion therapy (sur-
gery or IA thrombolysis) over no reperfusion
therapy (Grade 2C); we recommend surgery
over IA thrombolysis (Grade 1B). In patients
undergoing IA thrombolysis, we suggest recom-
binant tissue-type plasminogen activator (rt-PA)
or urokinase over streptokinase (Grade 2C).
7.0 Endovascular Revascularization in Patients With
Symptomatic PAD
7.1. For patients undergoing peripheral artery
percutaneous transluminal angioplasty with
or without stenting, we recommend long-
term aspirin (75-100 mg/day) or clopidogrel
(75 mg/day) (Grade 1A). For patients under-
going peripheral artery percutaneous translu-
minal angioplasty with stenting, we suggest
single rather than dual antiplatelet therapy
(Grade 2C).
Values and preferences: Patients who place a high
value on an uncertain reduction in the risk of limb
loss and a relatively low value on avoiding a definite
increased risk of bleeding are more likely to choose to
use dual antiplatelet therapy.
8.0 Antithrombotic Therapy Following Peripheral
Artery Bypass Graft Surgery
8.1-8.4. We recommend one of the following
antithrombotic regimens to be continued long-
term following peripheral artery bypass graft
surgery over no antithrombotic treatment:
aspirin 75 to 100 mg daily or clopidogrel 75 mg
daily (all Grade 1A). We recommend single anti-
platelet therapy over antiplatelet therapy and
warfarin (Grade 1B). In patients undergoing
below-knee bypass graft surgery with prosthetic
grafts, we suggest clopidogrel 75 mg/d plus
aspirin (75-100 mg/d) over aspirin alone for
1 year (Grade 2C). For all other patients, we
suggest single over dual antiplatelet therapy
(Grade 2B).
9.0 Patients With Carotid Artery Stenosis
9.1. For patients with asymptomatic carotid ste-
nosis, we suggest aspirin 75 to 100 mg daily over
no aspirin therapy (Grade 2B).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 37S
Remarks: Aspirin slightly reduces total mortality
regardless of cardiovascular risk profile if taken over
10 years. In people at moderate to high risk of car-
diovascular events, the reduction in MI is closely bal-
anced with an increase in major bleeds. Whatever
their risk status, people who are averse to taking
medication over a prolonged time period for very
small benefits will be disinclined to use aspirin for
primary prophylaxis.
9.2-9.3. In patients with symptomatic carotid ste-
nosis (including recent carotid endarterectomy),
we recommend long-term antiplatelet therapy
with clopidogrel (75 mg once daily) or aspirin-
extended-release dipyridamole (25 mg/200 mg bid)
or aspirin (75-100 mg once daily) over no anti-
platelet therapy (Grade 1A). We suggest either
clopidogrel (75 mg once daily) or aspirin-extended-
release dipyridamole (25 mg/200 mg bid) over
aspirin (75-100 mg) (Grade 2B).
VTE, Thrombophilia, Antithrombotic
Therapy, and Pregnancy
For further details, see Bates et al.14
2.0 Maternal Consequences of Antithrombotic Therapy
Use During Pregnancy
2.2.1. For pregnant patients, we recommend
LMWH for the prevention and treatment of
VTE, instead of UFH (Grade 1B).
3.0 Fetal Consequence of Antithrombotic Therapy
Use in Pregnant Women
3.0.1. For women receiving anticoagulation for
the treatment of VTE who become pregnant,
we recommend LMWH over VKAs during the
first trimester (Grade 1A), in the second and
third trimesters (Grade 1B), and during late preg-
nancy when delivery is imminent (Grade 1A).
3.0.2. For women requiring long-term VKAs who
are attempting pregnancy and are candidates
for LMWH substitution, we suggest perform-
ing frequent pregnancy tests and substituting
LMWH for VKAs when pregnancy is achieved
rather than switching to LMWH while attempt-
ing pregnancy (Grade 2C).
Remarks: Women who place little value on avoid-
ing the risks, inconvenience, and costs of LMWH
therapy of uncertain duration while awaiting preg-
nancy and a high value on minimizing the risks of
early miscarriage associated with VKA therapy are
likely to choose LMWH while attempting pregnancy.
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3.0.3. For pregnant women, we suggest lim-
iting the use of fondaparinux and parenteral
direct thrombin inhibitors to those with severe
allergic reactions to heparin (eg, HIT) who
cannot receive danaparoid (Grade 2C).
3.0.4. For pregnant women, we recommend
avoiding the use of oral direct thrombin (eg,
dabigatran) and anti-Xa (eg, rivaroxaban, apixa-
ban) inhibitors (Grade 1C).
4.0 Use of Antithrombotic Therapy in Nursing Women
4.0.1. For lactating women using warfarin,
acenocoumarol, or UFH who wish to breast-
feed, we recommend continuing the use of war-
farin, acenocoumarol, or UFH (Grade 1A).
4.0.2. For lactating women using LMWH, dana-
paroid, or r-hirudin who wish to breast-feed,
we recommend continuing the use of LMWH,
danaparoid, or r-hirudin (Grade 1B).
4.0.3. For breast-feeding women, we suggest
alternative anticoagulants rather than fonda-
parinux (Grade 2C).
4.0.4. For breast-feeding women, we recom-
mend alternative anticoagulants rather than
oral direct thrombin (eg, dabigatran) and fac-
tor Xa inhibitors (eg, rivaroxaban, apixaban)
(Grade 1C).
4.0.5. For lactating women using low-dose aspi-
rin for vascular indications who wish to breast-
feed, we suggest continuing this medication
(Grade 2C).
5.0 VTE in Patients Using Assisted Reproductive
Technology
5.1.1. For women undergoing assisted repro-
duction, we recommend against the use of rou-
tine thrombosis prophylaxis (Grade 1B).
5.1.2. For women undergoing assisted repro-
duction who develop severe ovarian hyperstim-
ulation syndrome, we suggest thrombosis
prophylaxis (prophylactic LMWH) for 3 months
postresolution of clinical ovarian hyperstimu-
lation syndrome rather than no prophylaxis
(Grade 2C).
Remarks: Women who are averse to taking medica-
tion for very small benefit and those who consider
self-injecting a considerable burden will be disin-
clined to use LMWH for extended thrombosis pro-
phylaxis. Given that the absolute benefit decreases as
time from the hyperstimulation event increases, such
Executive Summary
women will be very disinclined to continue prophy-
laxis throughout the entire resultant pregnancy.
6.0 VTE Following Cesarean Section
6.2.1. For women undergoing cesarean section
without additional thrombosis risk factors, we
recommend against the use of thrombosis pro-
phylaxis other than early mobilization (Grade 1B).
6.2.2. For women at increased risk of VTE after
cesarean section because of the presence of
one major or at least two minor risk factors,
we suggest pharmacologic thromboprophylaxis
(prophylactic LMWH) or mechanical prophy-
laxis (elastic stockings or intermittent pneumatic
compression) in those with contraindications
to anticoagulants while in hospital following
delivery rather than no prophylaxis (Grade 2B).
Remarks: The reduced bleeding risk with mechanical
prophylaxis should be weighed against the inconve-
nience of elastic stockings and intermittent pneu-
matic compression.
6.2.3. For women undergoing cesarean section
who are considered to be at very high risk for VTE
and who have multiple additional risk factors for
thromboembolism that persist in the puerperium,
we suggest that prophylactic LMWH be combined
with elastic stockings and/or intermittent pneu-
matic compression over LMWH alone (Grade 2C).
6.2.4. For selected high-risk patients in whom
significant risk factors persist following delivery,
we suggest extended prophylaxis (up to 6 weeks
after delivery) following discharge from the
hospital (Grade 2C).
7.0 Treatment of Patients With Proven Acute VTE
During Pregnancy
7.1.1. For pregnant women with acute VTE,
we recommend therapy with adjusted-dose
SC LMWH over adjusted-dose UFH (Grade 1B).
7.1.2. For pregnant women with acute VTE, we
recommend LMWH over VKA treatment ante-
natally (Grade 1A).
7.1.3. For pregnant women with acute VTE, we
suggest that anticoagulants should be contin-
ued for at least 6 weeks postpartum (for a min-
imum total duration of therapy of 3 months) in
comparison with shorter durations of treat-
ment (Grade 2C).
7.1.4. For pregnant women receiving adjusted-
dose LMWH therapy and where delivery is
planned, we recommend discontinuation of
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2012 American College of Chest Physicians
LMWH at least 24 h prior to induction of labor
or cesarean section (or expected time of neurax-
ial anesthesia) rather than continuing LMWH
up until the time of delivery (Grade 1B).
8.0 Prevention of Recurrent VTE in Pregnant Women
8.2.1. For all pregnant women with prior VTE,
we suggest postpartum prophylaxis for 6 weeks
with prophylactic- or intermediate-dose LMWH
or VKAs targeted at INR 2.0 to 3.0 rather than
no prophylaxis (Grade 2B).
8.2.2. For pregnant women at low risk of recur-
rent VTE (single episode of VTE associated with
a transient risk factor not related to pregnancy
or use of estrogen), we suggest clinical vigilance
antepartum rather than antepartum prophy-
laxis (Grade 2C).
8.2.3. For pregnant women at moderate to high
risk of recurrent VTE (single unprovoked VTE,
pregnancy- or estrogen-related VTE, or mul-
tiple prior unprovoked VTE not receiving long-
term anticoagulation), we suggest antepartum
prophylaxis with prophylactic- or intermediate-
dose LMWH rather than clinical vigilance or
routine care (Grade 2C).
8.2.4. For pregnant women receiving long-
term VKAs, we suggest adjusted-dose LMWH
or 75% of a therapeutic dose of LMWH through-
out pregnancy followed by resumption of long-
term anticoagulants postpartum, rather than
prophylactic-dose LMWH (Grade 2C).
9.0 Prevention of VTE in Pregnant Women With
Thrompophilia and No Prior VTE
9.2.1. For pregnant women with no prior his-
tory of VTE who are known to be homozygous
for factor V Leiden or the prothrombin 20210A
mutation and have a positive family history for
VTE, we suggest antepartum prophylaxis with
prophylactic- or intermediate-dose LMWH and
postpartum prophylaxis for 6 weeks with pro-
phylactic- or intermediate-dose LMWH or VKAs
targeted at INR 2.0 to 3.0 rather than no pro-
phylaxis (Grade 2B).
9.2.2. For pregnant women with all other throm-
bophilias and no prior VTE who have a positive
family history for VTE, we suggest antepartum
clinical vigilance and postpartum prophylaxis
with prophylactic- or intermediate-dose LMWH
or, in women who are not protein C or S defi-
cient, VKAs targeted at INR 2.0 to 3.0 rather
than routine care (Grade 2C).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 39S
9.2.3. For pregnant women with no prior his-
tory of VTE who are known to be homozygous
for factor V Leiden or the prothrombin 20210A
mutation and who do not have a positive family
history for VTE, we suggest antepartum clin-
ical vigilance and postpartum prophylaxis for
6 weeks with prophylactic- or intermediate-
dose LMWH or VKAs targeted at INR 2.0 to
3.0 rather than routine care (Grade 2B).
9.2.4. For pregnant women with all other throm-
bophilias and no prior VTE who do not have a
positive family history for VTE, we suggest
antepartum and postpartum clinical vigilance
rather than pharmacologic prophylaxis (Grade 2C).
10.0 Prevention of Pregnancy Complications in
Women With Thrombophilia
10.2.1. For women with recurrent early preg-
nancy loss (three or more miscarriages before
10 weeks of gestation), we recommend screening
for antiphospolipid antibodies (APLAs) (Grade 1B).
10.2.2. For women with a history of pregnancy
complications, we suggest not to screen for
inherited thrombophilia (Grade 2C).
10.2.3. For women who fulfill the laboratory
criteria for APLA syndrome and meet the clin-
ical APLA criteria based on a history of three
or more pregnancy losses, we recommend
antepartum administration of prophylactic- or
intermediate-dose UFH or prophylactic LMWH
combined with low-dose aspirin, 75 to 100 mg/d,
over no treatment (Grade 1B).
10.2.4. For women with inherited thrombo-
philia and a history of pregnancy complications,
we suggest not to use antithrombotic prophy-
laxis (Grade 2C).
11.0 Prevention of Recurrent Preeclampsia or Pregnancy
Loss in Women Without Known Thrombophilia
11.1.1. For women considered at risk for pre-
eclampsia, we recommend low-dose aspirin
throughout pregnancy, starting from the second
trimester, over no treatment (Grade 1B).
11.2.1. For women with two or more miscar-
riages but without APLA or thrombophilia, we
recommend against antithrombotic prophylaxis
(Grade 1B).
12.0 Prevention of Thromboembolism in Pregnant
Women With Mechanical Heart Valves
12.1.1. For pregnant women with mechanical
heart valves, we recommend one of the following
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anticoagulant regimens in preference to no
anticoagulation (all Grade 1A):
(a) Adjusted-dose bid LMWH throughout preg-
nancy. We suggest that doses be adjusted to
achieve the manufacturers peak anti-Xa LMWH
4 h postsubcutaneous-injection or
(b) Adjusted-dose UFH throughout pregnancy
administered subcutaneously every 12 h in
doses adjusted to keep the mid-interval acti-
vated partial thromboplastin time at least twice
control or attain an anti-Xa heparin level of
0.35 to 0.70 units/mL or
(c) UFH or LMWH (as above) until the 13th week,
with substitution by VKAs until close to delivery
when UFH or LMWH is resumed.
Remarks: For pregnant women with mechanical heart
valves, the decision regarding the choice of anti-
coagulant regimen is so value and preference depen-
dent (risk of thrombosis vs risk of fetal abnormalities)
that we consider the decision to be completely indi-
vidualized. Women of childbearing age and pregnant
women with mechanical valves, should be counseled
about potential maternal and fetal risks associated
with various anticoagulant regimens, including con-
tinuation of VKAs with substitution by LMWH or
UFH close to term, substitution of VKAs by LMWH
or UFH until the 13th week and then close to term,
and use of LMWH or UFH throughout pregnancy.
Usual long-term anticoagulants should be resumed
postpartum when adequate hemostasis is assured.
12.1.2. In women judged to be at very high risk
of thromboembolism in whom concerns exist
about the efficacy and safety of UFH or LMWH
as dosed above (eg, older generation prosthesis
in the mitral position or history of thrombo-
embolism), we suggest VKAs throughout preg-
nancy with replacement by UFH or LMWH
(as above) close to delivery rather than one of
the regimens above (Grade 2C).
Remarks: Women who place a higher value on avoid-
ing fetal risk than on avoiding maternal complica-
tions (eg, catastrophic valve thrombosis) are likely to
choose LMWH or UFH over VKAs.
12.1.3. For pregnant women with prosthetic
valves at high risk of thromboembolism, we
suggest the addition of low-dose aspirin, 75 to
100 mg/d (Grade 2C).
Antithrombotic Therapy in
Neonates and Children
For further details, see Monagle et al.15
Executive Summary
1.0. We suggest that where possible, pediatric
hematologists with experience in thromboem-
bolism manage pediatric patients with throm-
boembolism (Grade 2C). When this is not possible,
we suggest a combination of a neonatologist/
pediatrician and adult hematologist supported
by consultation with an experienced pediatric
hematologist (Grade 2C).
1.1 Heparin in Neonates and Children
1.1. We suggest that therapeutic unfraction-
ated heparin (UFH) in children is titrated to
achieve a target range of anti-Xa activity of
0.35 to 0.7 units/mL or an activated partial
thromboplastin time range that correlates to
this anti-Xa range or to a protamine titration
range of 0.2 to 0.4 units/mL (Grade 2C). We sug-
gest that when initiating UFH therapy, UFH
boluses be no greater than 75 to 100 units/kg
and that boluses be withheld or reduced if there
are significant bleeding risks (Grade 2C). We
suggest avoiding long-term use of therapeutic
UFH in children (Grade 2C).
1.2 LMWH in Neonates and Children
1.2. We suggest, for neonates and children
receiving either once- or twice-daily therapeutic
LMWH that the drug be monitored to a target
anti-Xa activity range of 0.5 to 1.0 units/mL in a
sample taken 4 to 6 h after SC injection or 0.5
to 0.8 units/mL in a sample taken 2 to 6 h after
SC injection (Grade 2C).
1.3 VKAs in Neonates and Children
1.3. We suggest, for children receiving VKAs,
that the drug be monitored to a target INR of
2.5 (range, 2.0-3.0), except in the setting of pros-
thetic cardiac valves where we suggest adher-
ence to the adult recommendations outlined in
the article by Whitlock et al in this supplement
(Grade 2C). We suggest that INR monitoring
with point-of-care monitors be made available
where resources make this possible (Grade 2C).
1.5 Aspirin in Children
1.5. We suggest that when aspirin is used for
antiplatelet therapy in children, it is used in
doses of 1 to 5 mg/kg per day (Grade 2C).
2.1 VTE in Neonates
2.1. We suggest that central venous access
devices (CVADs) or umbilical venous catheters
(UVCs) associated with confirmed thrombosis
be removed after 3 to 5 days of therapeutic anti-
coagulation rather than left in situ (Grade 2C).
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We suggest either initial anticoagulation or
supportive care with radiologic monitoring
for extension of thrombosis rather than no
follow-up (Grade 2C); however, in previously
untreated patients, we recommend the start of
anticoagulation if extension occurs (Grade 2C).
We suggest that anticoagulation should be with
either (1) LMWH or (2) UFH followed by LMWH.
We suggest a total duration of anticoagulation
of between 6 weeks and 3 months rather than
shorter or longer durations (Grade 2C). If either
a CVAD or a UVC is still in place on completion
of therapeutic anticoagulation, we suggest a
prophylactic dose of anticoagulation until such
time as the CVAD or UVC is removed (Grade 2C).
We suggest against thrombolytic therapy for
neonatal VTE unless major vessel occlusion is
causing critical compromise of organs or limbs
(Grade 2C). We suggest if thrombolysis is required,
tissue plasminogen activator (tPA) is used rather
than other lytic agents (Grade 2C), and we
suggest plasminogen (fresh frozen plasma)
administration prior to commencing therapy
(Grade 2C).
2.2-2.3 Renal Vein Thrombosis in Neonates
2.2. For unilateral renal vein thrombosis (RVT)
in the absence of renal impairment or extension
into the inferior vena cava (IVC), we suggest
either (1) supportive care with radiologic moni-
toring for extension of thrombosis (if extension
occurs we suggest anticoagulation) or (2) anti-
coagulation with UFH/LMWH or LMWH in
therapeutic doses rather than no therapy. If
anticoagulation is used, we suggest a total dura-
tion of between 6 weeks and 3 months rather
than shorter or longer durations of therapy
(Grade 2C). For unilateral RVT that extends into
the IVC, we suggest anticoagulation with UFH/
LMWH or LMWH for a total duration of
between 6 weeks and 3 months (Grade 2C).
2.3. For bilateral RVT with evidence of renal
impairment, we suggest anticoagulation with
UFH/LMWH or initial thrombolytic therapy
with tPA followed by anticoagulation with UFH/
LMWH (Grade 2C).
2.4 CVAD Prophylaxis in Neonates
2.4. For neonates with CVADs, we recommend
to maintain CVAD patency with UFH contin-
uous infusion at 0.5 units/kg per h over no
prophylaxis (Grade 1A) or intermittent local
thrombolysis (Grade 2C). For neonates with
blocked CVADs, we suggest local thrombolysis
after appropriate clinical assessment (Grade 2C).
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 41S
2.6 Thromboprophylaxis for Neonates and Children
With Blalock-Taussig Shunts and Modified Blalock-
Taussig Shunts (MBTS)
2.6. For neonates and children having modi-
fied MBTS, we suggest intraoperative UFH
therapy (Grade 2C). For neonates and children
after MBTS surgery, we suggest either aspirin
or no antithrombotic therapy as compared with
prolonged LMWH or VKAs (Grade 2C).
2.9-2.10 Therapy for Femoral Artery Thrombosis in
Neonates and Children
2.9. For neonates and children with acute fem-
oral artery thrombosis, we recommend thera-
peutic doses of IV UFH as initial therapy
compared with aspirin or no therapy (Grade 1B)
or LMWH (Grade 2C). We suggest subsequent
conversion to LMWH, or else continuation of
UFH, to complete 5 to 7 days of therapeutic
anticoagulation as compared with a shorter or
longer duration (Grade 2C).
2.10. For neonates and children with limb-
threatening or organ-threatening (via proximal
extension) femoral artery thrombosis who fail to
respond to initial UFH therapy and who have
no known contraindications, we recommend
thrombolysis (Grade 1C). For neonates and chil-
dren with femoral artery thrombosis, we recom-
mend surgical intervention compared with UFH
therapy alone when there is a contraindication
to thrombolytic therapy and organ or limb death
is imminent (Grade 1C).
2.11 Prophylaxis for Peripheral Arterial Catheters in
Neonates and Children
2.11. For neonates and children with periph-
eral arterial catheters in situ, we recommend
UFH continuous infusion at 0.5 units/mL at
1 mL/h compared with normal saline (Grade 1A).
2.12 Therapy for Peripheral Artery Thrombosis
Secondary to Peripheral Artery Catheters in Neonates
and Children
2.12. For neonates and children with a periph-
eral arterial catheter-related thromboembolism,
we suggest immediate removal of the catheter
(Grade 2B). For neonates and children with a
symptomatic peripheral arterial catheter-related
thromboembolism, we suggest UFH anticoag-
ulation with or without thrombolysis or surgical
thrombectomy and microvascular repair with
subsequent heparin therapy (Grade 2C).
2.13-2.14 Prophylaxis of Umbilical Arterial Catheters
in Neonates
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2.13. For neonates with umbilical arterial cath-
eters (UACs), we suggest UAC placement in a
high rather than a low position (Grade 2B).
2.14. For neonates with UAC, we suggest pro-
phylaxis with a low-dose UFH infusion via the
UAC (heparin concentration of 0.25-1 unit/mL,
total heparin dose of 25-200 units/kg per day) to
maintain patency (Grade 2A).
2.16 Prophylaxis for Cardiac Catheterization in
Neonates and Children
2.16. For neonates and children requiring
cardiac catheterization via an artery, we recom-
mend administration of IV UFH as thrombo-
prophylaxis over no prophylaxis (Grade 1A)
or aspirin (Grade 1B). For neonates and chil-
dren requiring cardiac catheterization via an
artery, we recommend the use of UFH doses
of 100 units/kg as a bolus compared with a
50-unit/kg bolus (Grade 1B). In prolonged pro-
cedures, we suggest further doses of UFH rather
than no further therapy (Grade 2B).
2.17 Cerebral Sinovenous Thrombosis in Neonates
2.17. For neonates with cerebral sinovenous
thrombosis (CSVT) without significant intracra-
nial hemorrhage, we suggest anticoagulation,
initially with UFH or LMWH and subsequently
with LMWH, for a total therapy duration
between 6 weeks and 3 months rather than
shorter or longer treatment duration (Grade 2C).
For neonates with CSVT with significant hemor-
rhage, we suggest either (1) anticoagulation or
(2) supportive care with radiologic monitoring
of the thrombosis at 5 to 7 days and anticoagula-
tion if thrombus extension is noted as compared
with no therapy (Grade 2C).
2.18-2.20 Arterial Ischemic Stroke in Neonates
2.18. For neonates with a first arterial ischemic
stroke (AIS), in the absence of a documented,
ongoing cardioembolic source, we suggest sup-
portive care over anticoagulation or aspirin
therapy (Grade 2C).
2.19. For neonates with a first AIS and a docu-
mented cardioembolic source, we suggest anti-
coagulation with UFH or LMWH (Grade 2C).
2.20. For neonates with recurrent AIS, we sug-
gest anticoagulant or aspirin therapy (Grade 2C).
2.21 Neonates With Purpura Fulminans
2.21. For neonates with clinical presentations of
homozygous protein C deficiency, we recom-
mend administration of either 10 to 20 mL/kg of
Executive Summary
fresh frozen plasma every 12 h or protein C
concentrate, when available, at 20 to 60 units/kg
until the clinical lesions resolve (Grade 1A). For
neonates with homozygous protein C deficiency,
after initial stabilization, we recommend long-
term treatment with VKA (Grade 1C), LMWH
(Grade 1C), protein C replacement (Grade 1B),
or liver transplantation (Grade 1C) compared with
no therapy.
2.22 DVT and PE in Children
2.22.1. In children with first VTE (CVAD and
non-CVAD related) we recommend acute anti-
coagulant therapy with either UFH or LMWH
(Grade 1B). We recommend initial treatment
with UFH or LMWH for at least 5 days (Grade
1B). For ongoing therapy, we recommend
LMWH or UFH. For patients in whom clinicians
will subsequently prescribe VKAs, we recom-
mend beginning oral therapy as early as day 1
and discontinuing UFH/LMWH on day 6 or later
than day 6 if the INR has not exceeded 2.0 com-
pared with no therapy (Grade 1B).
2.22.2. We suggest that children with idiopathic
VTE receive anticoagulant therapy for 6 to
12 months compared with no therapy (Grade 2C).
Values and preferences: Families who place a high
value on avoiding the unknown risk of recurrence in
the absence of an ongoing risk factor and a lower
value on avoiding the inconvenience of therapy
or potential impact of therapy on growth and devel-
opment and bleeding risk associated with anti-
thrombotic therapy are likely to choose to continue
anticoagulant therapy beyond 6 to 12 months.
2.22.3. In children with secondary VTE (ie, VTE
that has occurred in association with a clinical
risk factor) in whom the risk factor has resolved,
we suggest anticoagulant therapy be admin-
istered for 3 months (Grade 2C) as compared
with no further therapy. In children who have
ongoing, but potentially reversible risk factors,
such as active nephrotic syndrome or ongoing
asparaginase therapy, we suggest continuing
anticoagulant therapy beyond 3 months in either
therapeutic or prophylactic doses until the risk
factor has resolved (Grade 2C).
2.22.4. In children with recurrent idiopathic
VTE, we recommend indefinite treatment with
VKAs (Grade 1A).
2.22.5. In children with recurrent secondary
VTEs with an existing reversible risk factor
for thrombosis, we suggest anticoagulation until
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resolution of the precipitating factor but for a
minimum of 3 months as compared with no fur-
ther therapy (Grade 2C).
2.22.6. In children with a CVAD in place who
have a VTE, if a CVAD is no longer required or
is nonfunctioning, we recommend it be removed
(Grade 1B). We suggest at least 3 to 5 days of
anticoagulation therapy prior to its removal
rather than no anticoagulation prior to removal
(Grade 2C). If CVAD access is required and the
CVAD is still functioning, we suggest that the
CVAD remain in situ and the patient given
anticoagulants (Grade 2C). For children with a
first CVAD-related VTE, we suggest initial man-
agement as for secondary VTE as previously
described.
2.22.7. In children with CVAD in place who
have a VTE and in whom the CVAD remains
necessary, we suggest, after the initial 3 months
of therapy, that prophylactic doses of VKAs
(INR range, 1.5-1.9) or LMWH (anti-Xa level
range, 0.1-0.3 units/mL) be given until the CVAD
is removed (Grade 2C). If recurrent thrombosis
occurs while the patient is receiving prophy-
lactic therapy, we suggest continuing thera-
peutic doses until the CVAD is removed and
for a minimum of 3 months following the VTE
(Grade 2C).
2.23 Thrombolysis in Pediatric Patients With DVT
2.23. In children with VTE, we suggest that
thrombolysis therapy be used only for life- or
limb-threatening thrombosis (Grade 2C). If throm-
bolysis is used in the presence of physiologically
low levels or pathologic deficiencies of plas-
minogen, we suggest supplementation with plas-
minogen (Grade 2C). In children with VTE in
whom thrombolysis is used, we suggest systemic
thrombolysis or catheter-directed thrombolysis,
depending on institutional experience and, in
the latter case, technical feasibility.
2.24 Thrombectomy and IVC Filter Use in Pediatric
Patients With DVT
2.24. In children with life-threatening VTE, we
suggest thrombectomy (Grade 2C). In children
who have had a thrombectomy, we suggest anti-
coagulant therapy as per recommendation (2.22)
(Grade 2C). In children . 10 kg body weight with
lower-extremity VTE and a contraindication
to anticoagulation, we suggest placement of a
retrievable IVC filter (Grade 2C). In children
who receive a filter, we suggest that the filter be
removed as soon as possible if thrombosis is not
CHEST / 141 / 2 / FEBRUARY, 2012 SUPPLEMENT 43S
present in the basket of the filter and when con-
traindication to anticoagulation is resolved
(Grade 2C). In children who receive an IVC fil-
ter, we recommend appropriate anticoagulation
for VTE (see 1.2) as soon as the contraindication
to anticoagulation is resolved (Grade 1C).
2.25 DVT in Children With Cancer
2.25. In children with cancer, we suggest that
management of VTE follow the general recom-
mendations for management of VTE in children.
We suggest the use of LMWH in the treatment
of VTE for a minimum of 3 months until the
precipitating factor has resolved (eg, use of aspar-
aginase) (Grade 2C).
Remarks: The presence of cancer, the need for surgery,
chemotherapy, or other treatments may modify the
risk-benefit ratio for treatment of VTE, and clinicians
should consider these factors on an individual basis.
2.26 Children With APLAs and DVT
2.26. For children with VTE in the setting of
APLAs, we suggest management as per general
recommendations for VTE management in
children.
2.27 Children With DVT and Positive Inherited
Thrombophilia Testing
2.27. For children with VTE, independent of
the presence or absence of inherited thrombo-
philic risk factors, we suggest that the duration
and intensity of anticoagulant therapy as per
2.22.
2.28 Children With VTE and Structurally Abnormally
Venous Systems
2.28. For children with first VTE secondary
to structural venous abnormalities, we suggest
anticoagulation as per other spontaneous VTE
(2.22) and consideration of subsequent percuta-
neous or surgical interventions, depending on
patient factors and institutional experience.
For children with recurrent VTE secondary to
structural venous abnormalities, we suggest
indefinite anticoagulation unless successful per-
cutaneous or surgical interventions can be per-
formed (Grade 2C).
2.29 Children With Right Atrial Thrombosis
2.29. For children with right atrial thrombosis
related to CVAD, we suggest removal of the
CVAD with or without anticoagulation, depend-
ing on the individual risk factors, compared with
leaving the CVAD in situ (Grade 2C). For children
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2012 American College of Chest Physicians
with large (. 2 cm) mobile right atrial thrombo-
sis, we suggest anticoagulation, with appropri-
ately timed CVAD removal, and consideration of
surgical intervention or thrombolysis based on
individualized risk-benefit assessment compared
with no anticoagulation therapy (Grade 2C).
2.30-2.34 Children With CVADs
2.30. For CVADs, we suggest flushing with nor-
mal saline or heparin or intermittent recombi-
nant urokinase to maintain patency as compared
with no therapy (Grade 2C). For blocked CVADs, we
suggest tPA or recombinant urokinase to restore
patency (Grade 2C) . If after at least 30 min
following local thrombolytic instillation CVAD
patency is not restored, we suggest a second
dose be administered. If the CVAD remains
blocked following two doses of local thrombo-
lytic agent, we suggest radiologic imaging to
rule out a CVAD-related thrombosis (Grade 2C).
2.31. For children with short- or medium-term
CVADs, we recommend against the use of rou-
tine systemic thromboprophylaxis (Grade 1B).
2.34. For children receiving long-term home
total parenteral nutrition, we suggest thrombo-
prophylaxis with VKAs (Grade 2C).
2.35 Children Undergoing Glenn Procedure or
Bilateral Cavopulmonary Shunt
2.35. For children who have bilateral cavopul-
monary shunt, we suggest postoperative UFH
(Grade 2C).
2.36 Children Undergoing Fontan Surgery
2.36. For children after Fontan surgery, we rec-
ommend aspirin or therapeutic UFH followed
by VKAs over no therapy (Grade 1C).
2.37 Insertion of Endovascular Stents in Children
2.37. For children having endovascular stents
inserted, we suggest administration of UFH
perioperatively (Grade 2C).
2.38 Pediatric Patients With Dilated Cardiomyopathy
2.38. For pediatric patients with cardiomyopathy,
we suggest VKAs no later than their activation
on a cardiac transplant waiting list (Grade 2C).
Values and preferences: Parents who place a high
value on avoiding the inconvenience, discomfort,
and limitations of anticoagulant monitoring and a
lower value on the uncertain reduction in thrombotic
complications are unlikely to choose VKA therapy for
their children who are eligible for transplant.
Executive Summary
2.39 Children With Primary Pulmonary Hypertension
2.39. For children with primary pulmonary
hypertension, we suggest starting anticoagula-
tion with VKAs at the same time as other med-
ical therapy (Grade 2C).
2.40-2.42 Children With Biologic and Mechanical
Prosthetic Heart Valves
2.40-2.42. For children with biologic or mechan-
ical prosthetic heart valves, we recommend that
clinicians follow the relevant recommendations
from the adult population.
2.44 Children With Ventricular Assist Devices (VADs)
2.44. For children with VADs we suggest admin-
istration of UFH (Grade 2C). We suggest start-
ing UFH between 8 and 48 h following
implantation (Grade 2C). In addition, we suggest
antiplatelet therapy (either aspirin or aspirin
dipyridamole) to commence within 72 h of
VAD placement (Grade 2C). For children with
VAD, once clinically stable, we suggest switch-
ing from UFH to either LMWH or VKA (target
INR 3.0 range, 2.5-3.5) until transplanted or
weaned from VAD (Grade 2C).
2.45-2.46 Primary Prophylaxis for Venous Access
Related to Hemodialysis
2.45. For patients undergoing hemodialysis
via an arteriovenous fistula, we suggest rou-
tine use of VKAs or LMWH as fistula throm-
boprophylaxis as compared with no therapy
(Grade 2C).
2.46. For patients undergoing hemodialysis via
CVAD, we suggest routine use of VKAs or
LMWH for thromboprophylaxis as compared
with no therapy (Grade 2C).
2.47 Use of UFH or LMWH in Children Undergoing
Hemodialysis
2.47. For children having hemodialysis, we sug-
gest the use of UFH or LMWH during hemodi-
alysis to maintain circuit patency independent
of type of vascular access (Grade 2C).
2.48-2.50 Children With Kawasaki Disease
2.48. For children with Kawasaki disease, we
recommend aspirin in high doses (80-100 mg/kg
per day during the acute phase for up to 14 days)
as an antiinflammatory agent, then in lower
doses (1-5 mg/kg per day for 6 to 8 weeks) as an
antiplatelet agent (Grade 1B). For children with
Kawasaki disease, we recommend IV g-globulin
(2 g/kg, single dose) within 10 days of the onset
of symptoms (Grade 1A).
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2012 American College of Chest Physicians
2.49. For children with moderate or giant coro-
nary aneurysms following Kawasaki disease, we
suggest that warfarin in addition to low-dose
aspirin be given as primary thromboprophylaxis
(Grade 2C).
2.50. For children with Kawasaki disease who
have giant aneurysms and acute coronary artery
thrombosis, we suggest thrombolysis or acute
surgical intervention (Grade 2C).
2.51 CSVT in Children
2.51. For children with CSVT without significant
intracranial hemorrhage, we recommend antico-
agulation initially with UFH or LMWH and sub-
sequently with LMWH or VKA for a minimum of
3 months relative to no anticoagulation (Grade 1B).
In children who after 3 months of therapy still expe-
rience occlusion of CSVT or ongoing symptoms,
we suggest administration of a further 3 months
of anticoagulation (Grade 2C). For children with
CSVT with significant hemorrhage, we suggest ini-
tial anticoagulation as for children without hemor-
rhage or radiologic monitoring of the thrombosis
at 5 to 7 days and anticoagulation if thrombus
extension is noted at that time (Grade 2C). In chil-
dren with CSVT and potentially recurrent risk
factors (for example, nephrotic syndrome, aspar-
aginase therapy), we suggest prophylactic anti-
coagulation at times of risk factor recurrence
(Grade 2C). We suggest thrombolysis, thrombec-
tomy, or surgical decompression only in children
with severe CSVT in whom there is no improve-
ment with initial UFH therapy (Grade 2C).
2.52 AIS in Children
2.52. For children with acute AIS, with or with-
out thrombophilia, we recommend UFH or
LMWH or aspirin as initial therapy until dissec-
tion and embolic causes have been excluded
(Grade 1C). For children with acute AIS, we sug-
gest, once dissection and cardioembolic causes
are excluded, daily aspirin prophylaxis for a
minimum of 2 years as compared with no anti-
thrombotic therapy (Grade 2C). For children
receiving aspirin who have recurrent AIS or
transient ischemic attacks (TIAs), we suggest
changing to clopidogrel or anticoagulant therapy
with LMWH or VKA (Grade 2C). For children with
AIS, we recommend against the use of throm-
bolysis (tPA) or mechanical thrombectomy out-
side of specific research protocols (Grade 1C).
2.53 Embolic Stroke in Children
2.53. For AIS secondary to cardioembolic causes,
we suggest anticoagulant therapy with LMWH
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or VKAs for at least 3 months (Grade 2C). For
AIS secondary to cardioembolic causes in chil-
dren with demonstrated right-to-left shunts (eg,
PFO), we suggest surgical closure of the shunt
(Grade 2C).
2.54 Cerebral Arterial Dissection Underlying AIS
2.54. For AIS secondary to dissection, we sug-
gest anticoagulant therapy with LMWH or VKAs
for at least 6 weeks (Grade 2C). Ongoing treatment
will depend on radiologic assessment of degree
and extent of stenosis and evidence of recurrent
ischemic events.
2.55 Children With Cerebral Vasculopathies
2.55. For children with acute AIS secondary to
non-Moyamoya vasculopathy, we recommend
UFH or LMWH or aspirin for 3 months as initial
therapy compared with no treatment (Grade
1C). For children with AIS secondary to non-
Moyamoya vasculopathy, we suggest ongoing
antithrombotic therapy should be guided by
repeat cerebrovascular imaging.
2.56-2.57 Children With Moyamoya Disease
2.56. For children with acute AIS secondary to
Moyamoya, we suggest aspirin over no treat-
ment as initial therapy (Grade 2C).
2.57. For children with Moyamoya, we suggest
they be referred to an appropriate center for
consideration of revascularization.
Acknowledgments
Financial/nonfinancial disclosures: In summary, the authors
have reported to CHEST the following conflicts of interest:
Dr Crowther has served on various advisory boards, has assisted
in the preparation of educational materials, and has sat on data
safety and monitoring boards. His institution has received research
funds from the following companies: Leo Pharma A/S, Pfizer Inc,
Boerhinger Ingelheim GmbH, Bayer Healthcare Pharmaceuticals,
Octapharm AG, CSL Behring, and Artisan Pharma. Personal total
compensation for these activities over the past 3 years totals less
than US $10,000. Dr Gutterman has had the following relationships
that are entirely unrelated to the AT9 guidelines: ACCP President,
GlaxoSmithKline plc grant to study vasodilation in adipose tissue,
National Institutes of Health grant to study human coronary dila-
tion, and GE Healthcare consultation on a study for ECG evalua-
tion of chronic heart disease. Drs Guyatt and Schnemann are
co-chairs of the GRADE Working Group, and Dr Akl is a member
and prominent contributor to the GRADE Working Group.
Role of sponsors: The sponsors played no role in the develop-
ment of these guidelines. Sponsoring organizations cannot
recommend panelists or topics, nor are they allowed prepubli-
cation access to the manuscripts and recommendations. Guideline
panel members, including the chair, and members of the Health
& Science Policy Committee are blinded to the funding sources.
Further details on the Conflict of Interest Policy are available
online at http://chestnet.org.
Endorsements: This guideline is endorsed by the American
Association for Clinical Chemistry, the American College of Clin-
46S
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2012 American College of Chest Physicians
ical Pharmacy, the American Society of Health-System Pharma-
cists, the American Society of Hematology, and the International
Society of Thrombosis and Hematosis.
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Executive Summary
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2012 American College of Chest Physicians
 Executive Summary : Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed: American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines
Gordon H. Guyatt, Elie A. Akl, Mark Crowther, David D. Gutterman, Holger
J. Schunemann and for the American College of Chest Physicians
Antithrombotic Therapy and Prevention of Thrombosis Panel
Chest 2012;141; 7S-47S
DOI 10.1378/chest.1412S3
This information is current as of February 20, 2012
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